Don't chase the adenoma: A probabilistic approach to imaging before parathyroidectomy.

BACKGROUND: Preoperative imaging before parathyroidectomy can localize adenomas and reduce unnecessary bilateral neck explorations. We hypothesized that (1) the utility of preoperative imaging varies substantially depending on the preoperative probability of having adenoma(s) and (2) that a selective imaging approach based on this probability could avoid unnecessary patient costs and radiation. METHODS: We analyzed 3,577 patients who underwent parathyroidectomy for primary hyperparathyroidism from 2001 to 2022. The predicted probability of patients having single or double adenoma versus hyperplasia was estimated using logistic regression. We then estimated the relationship between the predicted probability of single/double adenoma and the likelihood that sestamibi or 4-dimensional computed tomography was helpful for operative planning. Current Medicare costs and published data on radiation dosing were used to calculate costs and radiation exposure from non-helpful imaging. RESULTS: The mean age was 62 ± 13 years; 78% were women. Adenomas were associated with higher mean calcium (11.2 ± 0.74 mg/dL) and parathyroid hormone levels (140.6 ± 94 pg/mL) than hyperplasia (9.8 ± 0.52 mg/dL and 81.4 ± 66 pg/mL). The probability that imaging helped with operative planning increased from 12% to 65%, as the predicted probability of adenoma increased from 30% to 90%. For every 10,000 patients, a selective approach to imaging that considered the preoperative probability of having adenomas could save patients up to $3.4 million and >239,000 millisieverts of radiation. CONCLUSION: Rather than imaging all patients with primary hyperparathyroidism, a selective strategy that considers the probability of having adenomas could reduce costs and avoid excess radiation exposure.

Cost-Effectiveness and Clinical Outcomes of Secondary Hyperparathyroidism Treatments in Patients with Chronic Kidney Disease.

The study addresses the challenge of treating secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) patients, focusing on the cost-effectiveness of surgical versus pharmacological interventions. Conducting a retrospective analysis on 152 CKD patients with SHPT at the Third People's Hospital of Chengdu, the study matched 80 patients into two groups: 40 undergoing parathyroidectomy with autotransplantation (PTX + AT) and 40 treated with calcimimetics. PTX + AT was more effective in alleviating symptoms, particularly bodily pain, and demonstrated greater cost-effectiveness over a long-term period compared to calcimimetics. This was especially significant in patients with PTH levels > 1800 pg/mL and hyperphosphatemia. Despite similar initial costs, PTX + AT led to a substantial decrease in expenses during the 2-5 years post-treatment period, PTX + AT results in an ICER of -RMB 26.71/QALY for the first post-treatment year and -RMB-111.9k/QALY for the 2-5 year period, indicating cost-effectiveness with reduced long-term costs. The study also found an increased economic burden in managing patients with hyperphosphatemia. Surgical intervention (PTX + AT) is advocated as the primary treatment strategy for severe SHPT in CKD patients, owing to its long-term economic and clinical advantages. The results underscore the need for a severity-based approach in treating SHPT.

Preliminary experience with the EleVision IR system in detection of parathyroid glands autofluorescence and perfusion assessment with ICG.

Background: Postoperative hypoparathyroidism remains the most frequent complication of neck endocrine surgery. In order to reduce the incidence of this feared complication, several systems for imaging of near infrared autofluorescence (NIRAF) have been invented to help surgeons identify parathyroid glands (PTGs) and evaluate their vascularization. We evaluated the efficacy of the EleVision IR system in thyroid and parathyroid surgery. Methods: We used the EleVision IR system in 25 patients who underwent thyroid/parathyroid surgery or both at our institution between December 2020 and July 2021. At various stages of the surgery, the surgeon first looked for PTGs with the naked eye and then completed the visual inspection with NIRAF imaging. We then compared both the naked eye and NIRAF-supported PTGs detection rates. At the end of surgery, we performed indocyanine green angiography of PTGs in 17 patients. Results: In total, we identified 80% of PTGs: 65% with the naked eye only and additional 15% with the assistance of the EleVision IR system. 14 of 17 patients evaluated by ICG angiography had at least one well-vascularized PTG. Only one of these patients (a case of subtotal parathyroidectomy for tertiary hyperparathyroidism) developed symptomatic postoperative hypocalcemia despite a normal parathormone level. The three other patients had at least one remaining moderately-vascularized PTG and only one patient developed transient postoperative hypoparathyroidism. Conclusion: We concluded that EleVision IR provides an efficient support for identification and evaluation of PTGs, and may be of great assistance in endocrine surgery. The images are easy to interpret even for less experienced surgeons thanks to the different types of color visualization and the possibility to measure the relative fluorescence intensity of PTGs and surrounding tissues.

Association of Implementation of Operating Room-Based Parathyroid Hormone Testing with Operative Time and Cost.

BACKGROUND: Intraoperative parathyroid hormone (IOPTH) testing facilitates focused parathyroidectomy to establish biochemical cure but may be time-consuming. A dedicated immunoassay machine was relocated to the operating room for IOPTH. These data seek to determine association of operating room-based IOPTH with operative time, laboratory turnaround time (TAT), and cost. METHODS: Patients who underwent parathyroidectomy from June 2017 to February 2020 were reviewed. Clinical and demographic data, operative time, and TAT were collected. Patients were compared by operation dates pre- or post-machine acquisition. A cost model was created to evaluate cost of care before and after operating room-based testing. RESULTS: A total of 285 patients were included. Post-machine, median operative time decreased from 69 minutes (interquartile range [IQR] 60 to 84) to 57 minutes (IQR 50 to 84.5), p 0.03. Additionally, median TAT for IOPTH values (preoperative, 0, 5, 10, and 15 minutes) decreased post-machine: time preoperative, 29 minutes (IQR 23 to 40) vs 18 minutes (IQR 17 to 23.5), p < 0.001; time 0, 33 minutes (IQR 27 to 39) vs 18.5 minutes (17.5 to 21), p < 0.001; time 5 minutes, 31 minutes (IQR 26 to 36) vs 20 minutes (IQR 18.5 to 21), p < 0.001; time 10 minutes, 32 minutes (IQR 27 to 39) vs 20 minutes (IQR 18.5 to 22.5), p < 0.001; and time 15 minutes, 30 minutes (IQR 26 to 36) vs 19 minutes (IQR 17 to 21), p < 0.001. Total costs pre- and post-machine were $4,442 and $4,111, respectively. With $331 cost reduction per operation and 127 operations per year, the IOPTH machine pays for itself in 3 years, or 378 surgeries, and saves $168,589 in the machine's remaining 4-year life span. CONCLUSIONS: Operating room-based parathyroid hormone testing results in improved operating productivity by decreasing result TAT and operative time and reduces cost.

Assessment of parathyroid gland cellularity by digital slide analysis.

BACKGROUND: Computer-aided examination of digital tissue images has attracted attention in recent years. Application in the field of parathyroid pathology has not been studied previously. It holds a potential to assist in the examination of parathyroid gland adenoma or hyperplasia. OBJECTIVES: To explore parathyroid cell detection of slide images by digital tissue analysis and compare the results to standard human processing. METHODS: 47 incisional biopsies of healthy appearing parathyroid glands were evaluated for their cellularity level. First, by the standard examination using microscopy by three independent pathologists. We compared the mean cellularity grading of the pathologists to the output of a computerized cell detection software. RESULTS: A disagreement was found between the standard human cellularity grading and the digital analysis output. However, the digital analysis reaches a 94% specificity and 48% sensitivity to predict high cellularity (>60% parenchymal cells). CONCLUSIONS: Digital analysis of parathyroid tissue can be used as a tool for hypercellularity elimination, therefore assisting in the diagnosis of parathyroid cell hyperplasia. Additional studies using more advanced algorithms are necessary for further precision enhancement.

Rapid intraoperative perfusion assessment of parathyroid adenomas with ICG using a wide-field portable hand-held fluorescence imaging system.

BACKGROUND: Fluorescence angiography (FA) using indocyanine green dye (ICG) has recently been introduced for real-time identification of parathyroid adenomas. However, time to peak fluorescence has not yet been critically evaluated. METHODS: This was a retrospective review of parathyroidectomies with ICG FA over a one-year period. RESULTS: There were 66 patients with average age of 64 years. The average time to initial fluorescence was 26.7 s and to peak fluorescence was 38.0 s. The time to saline flush administration significantly correlated with times to initial and peak fluorescence (p < .0001). The rate of in-situ fluorescence was 97%. The rates of suspected adenoma detection were 69% for sestamibi scan, 71% for ultrasound, and 96% for CT scan. Imaging was discordant in 13 cases (20%), with the adenoma located on the opposite side of the neck in 4 cases. CONCLUSIONS: ICG FA is a rapid and effective adjunct for the intraoperative identification of parathyroid adenomas.

Challenging NICE guidelines on parathyroid surgery.

BACKGROUND: National Institute of Clinical Excellence (NICE) recommend against routinely using Intra-Operative Parathyroid Hormone (IOPTH) for first-time parathyroid surgery due to its cost and minimal surgical benefit. The European Society of Endocrine Surgeons differ from this and recommends IOPTH with conflicting pre-operative or single imaging. NICE guidance acknowledged that this may change practice in larger centres. We devised a retrospective single-centre cohort study to analyse the impact of IOPTH on decision-making and cost-effectiveness. METHODOLOGY: First-time parathyroidectomy procedures for primary hyperparathyroidism were assessed between 2017 and 2019. Ultrasound (US) and Sestamibi with parathyroid single-photon emission with computed tomography (SPECT-CT) were compared with IOPTH. The contribution of IOPTH to cure and cost effectiveness ratio was calculated. RESULTS: 114 cases were included, with IOPTH performed in all cases, SPECT-CT in 112 and US in 108 cases. A cure rate of 99.1% (113/114) was achieved. 11.4% (13/114) of the cure rate was influenced by IOPTH (P 0.01), instigating further exploration when its levels didn't decrease. This included 7.1% (4/56) in the concordant-imaging cohort. IOPTH accuracy (96.5%) was significantly superior (P = 0.03) to both US (80%) and SPECT-CT (81%). Comparing the total costs for IOPTH testing over 2 years (£39,721) with 13 potential re-operative procedures in its absence (£63,536), a positive cost-effectiveness ratio of £1832 per re-operative procedure averted was achieved. CONCLUSION: Abandoning IOPTH in first-time parathyroid surgery is too ambitious when weighing the cost of re-operative surgery against cost savings obtained by using routine IOPTH to achieve an improved cure rate, even in concordant imaging.

Shifting from open to video-assisted parathyroidectomy: effect of the adjustment period on safety, clinical outcomes and cost.

INTRODUCTION: Bilateral neck exploration (BNE) has been the gold standard for the treatment of primary hyperparathyroidism (PHPT). Minimally invasive parathyroidectomy (MIP) has emerged as an alternative procedure for localised solitary adenomas. The most popular MIP techniques are the open MIP (OMIP) and the minimally invasive video-assisted parathyroidectomy (MIVAP). This study aims to assess whether we achieved a smooth transition from OMIP to MIVAP without compromising the results or increasing the cost. METHODS: A parathyroid adenoma was successfully localised preoperatively in 77/86 patients with PHPT. MIP was contraindicated in 27/86 cases. For MIVAP, a 5mm, 30 degree camera was employed, along with special instruments. RESULTS: Median preoperative parathyroid hormone (PTH) level was 145.9pg/dl (59-2,151) and median calcium (Ca) was 10.8mg/dl (9.3-19). Comparing MIVAP (N=31) with OMIP (N=28), there was no significant difference in the age, sex, location of the adenoma, preoperative PTH and Ca levels as well as in all the other factors compared, apart from the size of adenomas, which were bigger in the OMIP group (1.85cm vs 1.4cm, p=0.032). Moreover, cure rates, operating time, hospital stay and rates of postoperative normocalcaemia were similar between the two groups. CONCLUSIONS: Despite the learning curve, MIVAP was not found to be inferior to OMIP for localised adenomas. The final cost was no higher for MIVAP than OMIP with the use of common reusable instruments. This, along with surgeons' experience in parathyroid and endoscopic surgery facilitates a smooth and cost-effective transition from OMIP to MIVAP.

Parathyroid identification during thyroid and parathyroid operations: A pilot study evaluating a novel low cost autofluorescence based device.

BACKGROUND: The aim of this study was to develop a low-cost prototype near-infrared fluorescence device that enables contrast-free, real time, high-resolution intraoperative visualization of normal and pathological parathyroid glands (PGs) by imaging their autofluorescence (AF). METHODS: A novel near-infrared parathyroid AF (NIR-PAF) imaging device with visible laser PG targeting was developed. The device was evaluated during parathyroid and thyroid operations in a pilot clinical study. RESULTS: Overall, of the 6 parathyroidectomies carried out in the study population a parathyroid adenoma was found to exhibit AF ex vivo in 6/6 (100%) of cases, and in vivo in 3/3 (100%) of these cases. Two of 4 thyroidectomies were evaluated in vivo and all PGs (6 PGs total) were identified by the NIR-PAF device. The NIRPAF device cost less than $1200 Canadian to build. CONCLUSION: The inexpensive NIR-PAF device that we developed can successfully intraoperatively identify both normal and pathological PGs.

Implementation of a 4-dimensional computed tomography protocol for parathyroid adenoma localization.

PURPOSE: To present the results of our implementation of a four-dimensional computed tomography- (4DCT) based parathyroid localization protocol for primary hyperparathyroidism at a safety net hospital. METHODS: We performed a retrospective review of all patients who underwent parathyroidectomy for primary hyperparathyroidism at Elmhurst Hospital Center from June 2016 - September 2019. Patients treated prior to the implementation of 4DCT during October 2018 served as historical controls for comparison. Imaging-related costs and hospital charges were obtained from the Radiology Department for each patient. RESULTS: Forty-two patients underwent parathyroid surgery during the study period. Twenty patients had undergone 4DCT while 22 had nuclear medicine studies with or without ultrasonography. The sensitivity and specificity of 4DCT was 90.4% and 100% respectively, compared to 63% and 93.7% for nuclear imaging studies and 41% and 95% for ultrasound. The mean number of glands explored was significantly less in the 4DCT group, 1.8 ± 1.19 versus 2.77 ± 1.26 (p = 0.01). There was no increase in infrastructure or personnel costs associated with 4DCT implementation. CONCLUSIONS: 4DCT represents an increasingly common imaging modality for pre-operative parathyroid localization. Here we demonstrate that 4DCT is associated with a reduction in the number of glands explored and enables minimally invasive parathyroid surgery. 4DCT is a cost-effective and clinically sound localization study for parathyroid localization in an urban safety-net hospital.

Racial Disparities in Primary Hyperparathyroidism.

BACKGROUND: Racial disparities in surgery are increasingly recognized. We evaluated the impact of race on presentation, preoperative evaluation, and surgical outcomes for patients undergoing parathyroidectomy for primary hyperparathyroidism (PHPT). METHODS: We performed a retrospective cohort study of patients undergoing parathyroidectomy for PHPT at a single center (1997-2015). Patients were classified by self-identified race, as African-American or White. The primary outcome was disease severity at referral. The secondary outcome was completeness of preoperative evaluation. Operative success and surgical cure were evaluated. RESULTS: A total of 2392 patients were included. The majority of patients (87.6%) were White. African-American patients had higher rates of comorbid disease as well as higher preoperative calcium (10.9 vs.10.8 mg/dl, p < 0.001) and PTH levels (122 vs. 97 pg/ml, p < 0.001). White patients were more likely to have history of bone loss documented by DXA and nephrolithiasis. African-American patients had lower rates of complete preoperative evaluation including DXA scan. Operatively, African-American patients had larger glands by size (1.7 vs. 1.5 cm, p < 0.001) and mass (573 vs. 364 mg, p < 0.001). We observed similar operative success (98.9 vs. 98.0%, p = 0.355) and cure rates (98.3 vs. 97.0%, p = 0.756). CONCLUSIONS: At the time of surgical referral, African-American patients with PHPT have more biochemically severe disease and higher rates of incomplete evaluation. Operative success and cure rates are comparable.

Gonioprobe, an Innovative Gamma-probe to Guide Parathyroid Radioguided Surgery: First Clinical Experiences with Navigator and Lock-ontarget Functions.

BACKGROUND: Radioguided surgery represents a validated technique for the detection and the excision of abnormal parathyroid glands responsible for primary hyperparathyroidism (PHPT). To date little attention has been paid as to how the characteristics of gamma-probes can influence surgical procedure and time, thus having an impact on postoperative morbidity, hospitalization and costs. METHODS: We designed a new prototype of gamma-probe, the Gonioprobe, and tested its clinical utility in the operating room. Gonioprobe, thanks to its 5 scintillating independent crystals, performs the dual function of Navigator and Lock-on-target. These characteristics allow the immediate guidance of the surgeon's hand towards the source with very high precision, and with a much higher spatial resolution than commercial probes. Gonioprobe was used during intervention to detect abnormal parathyroid tissue, and to ensure no radioactivity in surgery bed after adenoma removal. RESULTS: We tested our gamma-probe on parathyroid adenomas particularly difficult to identify at a visual inspection due to anatomy modifications from previous neck surgery and/or characterized by uncommon localization. Moreover, parathyroid adenomas were hardly removable due to the proximity to the esophagus, neck vessels and/or recurrent laryngeal nerve (RLN). An intraoperative nerve monitoring system was used to protect the recurrent laryngeal nerve from injuries. Parathyroid hormone (PTH) assay and frozen biopsy confirmed the successful excision of the adenomas. CONCLUSION: The intraoperative use of the innovative Gonioprobe along with the nerve monitoring system allowed an accurate and safe removal of parathyroid adenomas and offered a significant advantage by reducing surgical time and postoperative complications, as well as hospitalization and costs.

Pre-operative imaging workup for surgical intervention in primary hyperparathyroidism: A tertiary referral center experience.

PURPOSE: Preoperative imaging in patients with primary hyperparathyroidism provides important localization information, allowing the surgeon to perform a focused surgery. However there are no evidence-based guidelines suggesting which preoperative imaging should be used, resulting in a risk of excessive prescription of exams and waste of economic resources. The main purpose of this study was to describe our experience on the performance of various imaging techniques for the preoperative localization of abnormal parathyroid gland/s, with a focus on the sensitivity and specificity of each technique. Secondly, we carried out an analysis of the cost utility of each technique in order to determine the most clinical and cost-effective combination of localization studies. MATERIALS AND METHODS: Records of 336 patients who underwent parathyroidectomy were retrospectively examined comparing imaging and intraoperative/histopathologic findings to evaluate the accuracy in parathyroid detection of each imaging technique. Costs were determined by regional health system reimbursement. RESULTS: We found that the sensitivity of color Doppler US was significantly higher than SPECT (p 0,023), while the sensitivity of 4D-CT was significantly better than US (p 0,029) and SPECT (p 0,0002). CONCLUSIONS: In experienced hands color Doppler US is a highly sensitive technique especially in patients with no thyroid diseases. In patients with concomitant thyroid pathology, the combination of US and 4D-CT represents a reliable localization technique.

Epidemiology and management of parathyroid gland disorders in Spain over 15 years: A retrospective multicentre analysis.

Parathyroid gland disorders are rare conditions with an incidence that displays great variability among populations. Its direct influence in calcium homeostasis originates variable symptoms that affect bone remodelling among other processes. This study aimed to provide data on the epidemiology and characteristics of patients admitted with these disorders in Spain between 2003 and 2017, and to analyse disease management and direct medical costs. Medical records in which a disorder of the parathyroid gland was registered as the admission motive were extracted from a nationwide hospital-discharge database via the Spanish Ministry of Health. Records from 12,903 patients were obtained, with predominance of female patients (74.70%) and of admissions due to hyperparathyroidism (90.23%). The number of patients admitted per year increased over the study period along the incidence of these disorders. The year 2017 incidence of hyperparathyroidism was 2.95 per 10,000, 4.03 per 10,000 in females and 1.37 in males; the same year, the incidence of hypoparathyroidism was 0.17 per 10,000. Length of hospital stay was significantly extended in patients with hypoparathyroidism (7.16 days), admitted mostly due to emergencies. Heart failure was diagnosed in more than 20% of admissions in patients with secondary and tertiary hyperparathyroidism and hypoparathyroidism, while this last group displayed the highest levels of mineral metabolism disruption. Parathyroidectomy was performed in 78.95% of all admissions for primary hyperparathyroidism. The total annual direct medical cost parathyroid gland disorders has increased over the study period, due to the increase of the costs associated to hyperparathyroidism, whereas the cost per patient remained relatively stable, with an average of €3,748, €3,430 and €3,737 for patients with hyperparathyroidism, hypoparathyroidism and other disorders of the parathyroid gland, respectively. This study provides novel data to extend the scarce available knowledge on parathyroid gland disorders' epidemiology and management in Spain.

Surgery versus Imaging in Non-Localizing Primary Hyperparathyroidism: A Cost-Effectiveness Model.

OBJECTIVE: To determine whether advanced imaging is cost-effective compared to primary bilateral neck exploration in the management of non-localizing primary hyperparathyroidism. STUDY DESIGN: Cost-effectiveness analysis. METHODS: Cost-effectiveness analysis based on decision tree model and available Medicare financial data using data from 347 consecutive patients having parathyroidectomy for primary hyperparathyroidism with either 1) positive, concordant ultrasound and sestamibi or 2) negative sestamibi and negative ultrasound. RESULTS: Bilateral neck exploration (BNE) costs $9578 and has a success rate of 97.3%. Single photon emission computed tomography (SPECT) + minimally invasive parathyroidectomy (MIP) was modeled to have a total cost of $8197 with a success rate of 98.6%. SPECT/computed tomography (CT) + MIP was modeled to have a total cost of $8271 and a 98.9% success rate. Four-dimensional (4D)-CT + MIP was modeled to cost $8146 with a success rate of 99%. Incremental cost-effectiveness ratios (IECR) (as compared to BNE) were -536.1, -605.5, and -701.6 ($/percent cure rate) for SPECT, SPECT/CT, and 4D-CT respectively. One-way sensitivity analyses demonstrate the change in IECR and cut-off points (IECR = 0) for four major variables. CONCLUSIONS: In patients with non-localizing primary hyperparathyroidism, advanced imaging is associated with cost-savings compared to routine bilateral neck exploration. Increased cost-savings were predicted with increased imaging accuracy and decreased imaging costs. Increasing time for BNE or decreasing time for MIP were associated with increased cost savings. LEVEL OF EVIDENCE: III Laryngoscope, 2020.

Autofluorescence imaging of parathyroid glands: An assessment of potential indications.

BACKGROUND: The aim of this study was to determine both the accuracy of near infrared fluorescence imaging to detect parathyroid glands and the potential indications of near infrared fluorescence imaging in thyroid and parathyroid surgery by correlating the autofluorescence signature with the pathologic specimen. METHODS: This was an institutional review board-approved, prospective study of patients undergoing thyroidectomy and parathyroidectomy with near infrared fluorescence imaging. Each specimen sent to pathology was inspected with near infrared fluorescence imaging and predicted to be either parathyroid or non-parathyroid tissue by its autofluorescence signature and then correlated with the pathologic findings. RESULTS: Autofluorescence was demonstrated to be present in 98% of the parathyroid glands, with 23% identified correctly with infrared based on the autofluorescence signature before visual identification by the surgeon. There were 550 specimens that were imaged with autofluorescence and then sent to pathology. For these samples, sensitivity, specificity, and positive and negative predictive values to predict parathyroid tissue were 98.5%, 97.2%, 95.1%, and 99.1%. In 5% of the total thyroidectomy specimens, incidentally resected parathyroid glands were identified with autofluorescence, leading to their subsequent reimplantation. In patients with parathyroid disease and negative preoperative localization, 21% of abnormal glands were recognized with autofluorescence before visual identification by the surgeon. CONCLUSION: Although the ability of infrared autofluorescence to confirm the presence of parathyroid tissue within surgical specimens was high, its power to find parathyroid glands in situ before visual recognition by surgeons was low. These advantages and limitations should be kept in mind when incorporating this technology into an endocrine surgical practice. Once a parathyroid seems to have been identified by the surgeon or tissue that looks like a parathyroid gland is identified, the autofluorescence signature is a very accurate assurance of parathyroid tissue.

Robot-Assisted Endocrine Surgery: Indications and Drawbacks.

BACKGROUND: Over the last few decades, robotic surgery with the da Vinci system has become increasingly prevalent. Endocrine surgeons are witnessing a rapid growth in enthusiasm for robotic approaches for treating thyroid, parathyroid, and adrenal disease. For carefully selected patients, the robotic system may be the preferred technique, although its use remains controversial and indications are in evolution. The goal of this article is to review current robotic procedures for thyroidectomy, parathyroidectomy, and adrenalectomy, and scrutinize the existing literature for application of these approaches. METHODS: We systematically searched and reviewed relevant articles on PubMed and MEDLINE databases for robotic or robot-assisted thyroidectomy, parathyroidectomy, or adrenalectomy. RESULTS: The safety and feasibility for robotic thyroidectomy, parathyroidectomy, and adrenalectomy have been repeatedly demonstrated. Although robotic thyroid and parathyroid surgery offers better cosmetic results compared to the conventional open operation, remote-access techniques introduce new risks. Similar outcomes have been reported for laparoscopic and robotic adrenalectomy, but robot-assisted techniques may extend the capabilities of minimally invasive surgery, particularly performing subtotal adrenalectomy. CONCLUSIONS: While robotic procedures offer better ergonomics for the endocrine surgeon and improved cosmesis for the patient, the major drawback to the robot system almost universally is the higher cost. With new robotically assisted surgical devices on the way that could drive down costs and speed up innovation, the indications for robotic endocrine surgery may greatly expand.

Transoral Thyroid and Parathyroid Surgery Vestibular Approach: A Framework for Assessment and Safe Exploration.

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new approach to the central neck that avoids an anterior cervical incision. This approach can be performed with endoscopic or robotic assistance and offers access to the bilateral central neck. It has been completed safely in both North American and, even more extensively, international populations. With any new technology or approach, complications during the learning curve, expense, instrument limitations, and overall safety may affect its ultimate adoption and utility. To ensure patient safety, it is imperative to define steps that should be considered by any surgeon or group before adoption of this new approach.

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations.

Robotic parathyroidectomy represents a novel surgical approach in the treatment of primary hyperparathyroidism when the parathyroid adenoma has been pre-operatively localised. It represents the "fourth generation" in the evolution of parathyroid surgery following a process of surgical evolution from cervicotomy and 4-gland exploration to a variety of minimally invasive, open and endoscopic, targeted approaches. The existing evidence (levels 2-3) supports it as a feasible and safe technique with equivalent results to targeted open parathyroidectomy for primary hyperparathyroidism in carefully selected patients. However, it takes longer to perform and is more costly than conventional parathyroidectomy. It offers superior cosmesis by completely avoiding a neck scar making it a valid option for those patients who for biological and/or cultural reasons may wish to avoid a neck scar. Robotic parathyroidectomy is not for every patient, surgeon, or hospital. Its application should be confined to high-volume centres and experienced surgeons. Intensive training and proctorship are required for its safe implementation combined with careful patient selection. This particularly relates to the patient's body habitus (BMI < 30 kg/m2) and concordance among the different imaging modalities used pre-operatively. With robotic market competition driving down costs, its role may change. For now, robotic parathyroidectomy occupies a niche role and can only be justified in a select subset of patients.