A female with frequent history of renal stones presented with severe bone pain. Laboratory findings are indicative of primary hyperparathyroidism which is secondary to parathyroid hyperplasia. Treatment is:

Primary parathyroid hyperplasia involves all of the parathyroid glands. Microscopically, there are two types: chief cell hyperplasia and water-clear cell (wasserhelle) hyperplasia. Hyperplastic glands vary considerably in size but are usually larger than normal (65 mg). When all parathyroid glands are hyperplastic, the gland should be subtotally resected, leaving a 50 mg remnant, and confirmed histologically before removal of the remaining glands. The upper thymus and perithymic tract should be removed in patients with hyperplasia, because a fifth parathyroid gland is present in 15% of cases. Ref: Dohey G.M. (2010). Chapter 16. Thyroid & Parathyroid. In G.M. Dohey (Ed), CURRENT Diagnosis & Treatment: Surgery, 13e.