Minimizing cost and maximizing success in the preoperative localization strategy for primary hyperparathyroidism.

Ultrasonography of the thyroid, parathyroid, and soft tissues of the neck should always be performed before parathyroidectomy. The most cost-effective localization strategies seem to be ultrasonography followed by four-dimensional computed tomography (4DCT) or ultrasonography followed by sestamibi ± 4DCT. These localization strategies are highly dependent on the quality of imaging. Surgeons should critically evaluate the imaging and operative data at their own institution to determine the best preoperative localization strategy before parathyroidectomy. Surgeons should communicate with the referring physicians about the best localization algorithms in the local area and become the decision maker as to when to obtain them.