This study aimed to identify independent risk factors associated with pathological subtypes, disease progression, and adverse outcomes in Primary hyperparathyroidism (PHPT) by analyzing clinical characteristics, thereby informing individualized therapeutic strategies.A retrospective analysis was conducted on 164 PHPT patients treated at Beijing Tongren Hospital from May 2009 to December 2024. The analysis encompassed demographic data, preoperative evaluations, surgical details, histopathological reports, and postoperative metabolic parameters.PHPT predominantly affected females, with 84.1% of cases diagnosed incidentally during routine examinations. Preoperative ultrasonography and radionuclide imaging demonstrated high diagnostic accuracy for lesion localization (97.4% and 75.4%, respectively). Parathyroidectomy effectively normalized serum calcium, Phosphate, and parathyroid hormone (PTH) levels (P < .001). However, delayed postoperative PTH recovery correlated with advanced age (P = .038), elevated preoperative PTH and calcium levels (P < .001), and larger lesion size (> 3 cm, P < .001). Among patients with preoperative hypercalcemia, male sex (p = .039) and relatively lower baseline serum calcium levels (p = .004), combined with baseline hypophosphatemia (p = .013), were associated with an increased risk of transient or permanent postoperative hypoparathyroidism. Benign solitary adenomas showed an 8.695-fold higher treatment efficacy than malignant lesions. Preoperative phosphate levels (P = .037) and lesion size (P = .037) emerged as discriminative predictors for pathological subtypes, while severe preoperative hypophosphatemia independently indicated poor therapeutic outcomes. Smaller lesions correlated with better postoperative calcium-phosphate recovery, whereas preoperative hypercalcemia and larger lesion volume significantly influenced PTH improvement magnitude (P < .001).Our findings affirmed parathyroidectomy's central role in PHPT management, highlighting substantial differences in treatment responses between benign and malignant cases. The study establishes a clinical decision-making framework combining preoperative imaging volumetry with serum PTH-calcium-phosphate profiling, enhancing pathological differentiation, guiding surgical planning, and predicting postoperative recovery trajectories. These insights enable more tailored therapeutic approaches, though validation through multicenter prospective studies remains essential for refining prognostic models and optimizing treatment protocols.© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.