Background: Different opinions exist on the surgical treatment in primary (pHPT) and secondary (sHPT) hyperparathyroidism due to parathyroid hyperplasia, i.e. subtotal parathyroidectomy (SPTx) v/s total parathyroidectomy and autotransplantation (TPTx). We analyse the advantages and disadvantages obtained by these different treatments. Methods: From 1977 to 1991, 219 patients with primary HPT (199 pts) and secondary HPT (20 pts) underwent parathyroid exploration. Of the patients with pHPT, 31 (15.6%) had parathyroid hyperplasia; of these, 27 underwent SPTx and 4 TPTx. In patients with sHPT we performed 15 SPTx and 5 TPTx. Results: At 5-18 months follow-up, 26 (83.9%) patients with pHPT have become normocalcemic, 3 (SPTx) have been operated on for persistent or recurrent HPT and 2 (SPTx) are hypocalcemic. Three years after operation, 11 out of 15 patients treated by SPTx for sHPT and 4 out of 5 pts treated by TPTx showed a significant improvement in the clinical and radiological picture of disease, 5 and 10 years respectively after TPTx 2 out of 5 patients underwent excision of the implant. Conclusions: TPTx is the treatment of choice in pHPT patients, whereas in sHPT we prefer SPTx if the patient cannot subsequently undergo a renal transplant.