Association of combined near-infrared autofluorescence and indocyanine green angiography with immediate and permanent postoperative hypoparathyroidism after thyroid surgery: a propensity score-matched analysis.

Hypoparathyroidism remains the most frequent complication after thyroid surgery and is mainly related to inadvertent parathyroid excision or gland devascularization. Near-infrared autofluorescence (NIRAF) enables real-time identification of parathyroid glands, whereas indocyanine green angiography (ICGa) allows intraoperative assessment of gland perfusion. Their combination may improve parathyroid outcomes. We conducted a retrospective cohort study with propensity score matching including adult patients undergoing primary bilateral thyroid resection between October 2023 and February 2025 at a high-volume endocrine referral centre. During the study period, 3317 thyroid procedures were performed, and 2277 patients met the inclusion criteria and were stratified into conventional naked-eye surgery (NE) and combined NIRAF/ICGa groups (1956 vs. 321, respectively). The primary endpoint was immediate and permanent hypoparathyroidism. Secondary endpoints included hypocalcaemia, inadvertent parathyroid excision, operative time, and postoperative hospital stay. A subgroup analysis was performed in patients with thyroid malignancy. After matching, immediate hypoparathyroidism was significantly lower in the NIRAF/ICGa group (35.5% vs. 45.2%; p = 0.016), whereas permanent hypoparathyroidism showed a favourable non-significant reduction (2.2% vs. 4.7%; p = 0.129). Hypocalcaemia rates were similar between groups, while hospital stay was shorter in the NIRAF/ICGa group (p < 0.001), with comparable operative times. In the matched malignant subgroup, both immediate (38.6% vs. 50.3%; p = 0.045) and permanent hypoparathyroidism (0.7% vs. 5.5%; p = 0.036) were significantly lower in the NIRAF/ICGa group. Inadvertent parathyroid excision also showed a favourable trend after matching (16.5% vs. 21.8%; p = 0.109). Combined NIRAF/ICGa was associated with lower immediate hypoparathyroidism overall and lower immediate and permanent hypoparathyroidism in the matched malignant subgroup, without prolonging operative time.