Despite advancements in the medical management of secondary hyperparathyroidism, parathyroidectomy is still necessarily in some patients. However, patients' selection, optimal surgical intervention and long-term outcome are still not well-defined and very challenging for the practicing nephrologists. In this manuscript we will attempt to answer several questions related to parathyroidectomy in dialysis patients. We will discuss the indications, the appropriate parathyroidectomy surgical techniques and current guidelines for parathyroidectomy. We will also discuss short- and long-term outcome and analyze the pros and cons of the procedure. It is readily apparent that the performance of parathyroidectomy in dialysis patients should be highly individualized.