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Considering that surgery is the only potentially curable option for patients with PHPT, there is universal agreement that all symptomatic as well as asymptomatic patients with significant kidney and bone signs of the disease, have clear indications to surgical treatment. Less certain are patients who do not meet the criteria and, in particular, do not experience hypercalcemia. The Fourth International Workshop on the management of symptomatic PHPT [25] proposed an algorithm for the management of NPHPT patients; the panel of experts suggested, based on the monitoring of serum calcium and PTH annually and bone density by DXA (dual-energy X-ray absorptiometry) every 1–2 years, to consider surgery in the following conditions:

•Progression to HPHPT: indication to parathyroidectomy according to the guidelines;

•Progression of the disease, that means worsening of BMD or occurrence of an osteoporotic fracture and/or diagnosis of kidney stones or nephrocalcinosis.

Successful parathyroidectomy has been reported to be followed at 1 year by a significant individual BMD gain in nearly half of NPHPT patients with osteoporosis. Elevated alkaline phosphatase levels above the median could contribute to the therapeutic decision in this context [48, 49].

From a surgical point of view, it should be considered that 63% of PHPT patients with preoperative normal ionized calcium had an adenoma involving a single gland, which was correctly identified by preoperative imaging in 60% of cases. Intraoperative PTH assay identified the cure in 75% of PHPT patients with normal ionized calcium [50].