The advent of intraoperative parathyroid hormone (IOPTH) monitoring transformed parathyroid surgery, limiting the need for bilateral neck exploration and its concomitant risks, including recurrent laryngeal nerve injury, hypoparathyroidism and transient or permanent hypocalcemia. Monitoring parathyroid hormone levels intraoperatively to verify surgical cure facilitated the management of parathyroid disease with a minimally invasive approach via focused or unilateral neck exploration. The added costs and operative time associated with IOPTH monitoring, however, hindered its universal adoption. Preoperative localization of parathyroid adenoma with imaging modalities including ultrasound, sestamibi, or 4D-CT scan can provide reasonable diagnostic certainty to facilitate focused parathyroid exploration. In this context, the role of intraoperative parathyroid hormone (IOPTH) monitoring remains a matter of debate; the value added by IOPTH monitoring in the setting of preoperative localization of parathyroid disease must be weighed against its cost, cure rates, institution-specific rates of multi-gland disease and the ongoing evolution and availability of imaging technology.