The diagnosis and treatment of primary hyperparathyroidism (PHPT) have undergone significant transformations over the past quarter-century, particularly in the shift from four-gland explorations to minimally invasive parathyroidectomy (MIP). Coinciding with this evolution, radiology has faced increasing demands for precise preoperative lesion localization. This chapter focuses on two pivotal imaging modalities in this context: four-dimensional computed tomography (4D CT) and magnetic resonance imaging (MRI). These advanced techniques (specifically 4D CT) offer enhanced sensitivity and specificity, superior adenoma localization, comprehensive presurgical evaluation of adjacent anatomical structures, and improved identification of ectopic adenomas. The chapter aims to provide an in-depth exploration of the growing importance of advanced cross-sectional imaging modalities in both diagnosing and preoperatively assessing patients with PHPT.