Background The United Kingdom Registry of Endocrine and Thyroid Surgeons is a national database holding details on > 28,000 parathyroidectomies. Methods An extract (2004–2017) of the database was analysed to investigate the reported efficacy, safety and use of intra-operative surgical adjuncts in targeted parathyroidectomy (tPTx) and bilateral neck exploration (BNE) for adult, first-time primary hyperparathyroidism (PHPT). Results 50.9% of 21,738 cases underwent tPTx. Excellent short-term (median follow-up 35 days) post-operative normocalcaemia rates were reported overall (tPTx 96.6%, BNE 94.5%, p  < 0.05) and in image-positive cases (tPTx 96.7%, BNE 96%, p  < 0.05). Intra-operative PTH improved overall normocalcaemia rates (tPTx 97.8% vs 96.3%, BNE 95% vs 94.4%: both p  < 0.05). Intra-operative nerve monitoring reduced vocal cord (VC) dysfunction in image-positive tPTx, but not in BNE (97.8% vs 93.2%, p  < 0.05). Complications were higher following BNE (7.4% vs 3.8%, p  < 0.05), especially hypocalcaemia (5.3% vs 2%, p  < 0.05). There was no difference in rates of subjective dysphonia following tPTx or BNE (2.4% vs 2.3%, p  > 0.05), nor any difference in VC dysfunction when formally examined (4.9% vs 4.1%, p  > 0.05). Conclusions In image-positive, first time, adult PHPT cases, tPTx is as safe and effective as BNE, with both achieving excellent short-term results with minimal complications.