© 2018 Elsevier Inc. Background: The cost-effectiveness of routine preoperative imaging for patients undergoing parathyroidectomy is controversial. The purpose of this study is to evaluate whether omission of routine preoperative imaging would affect efficiency or safety of parathyroidectomy. Methods: We implemented a no-imaging protocol for patients with primary hyperparathyroidism and no prior neck surgery. If the patient did not have preoperative parathyroid imaging before evaluation by a surgeon, no radiologic studies were ordered, and the patient was scheduled for parathyroidectomy. We used propensity matching to address differences between the imaging and no-imaging groups. Results: From 2000 to 2015, 83 patients underwent parathyroidectomy without imaging compared to 1245 patients with preoperative imaging. We successfully matched 64 patients with no preoperative imaging to equivalent patients who had imaging prior to surgery. Median age was 60 y, and 84% were women. There was no significant difference in operative time between patients with and without preoperative imaging (84 min for both groups, P < 0.32). Intraoperative parathyroid hormone levels dropped by at least 50% in all patients without preoperative imaging and in 98% of patients with imaging (P < 0.24). Neither group had recurrences 6 mo after surgery. Overall complication rates in the no-imaging (5%) and the imaging group (11%) were also similar (P < 0.18). Conclusions: Parathyroid surgery without preoperative imaging is safe, effective, and offers equivalent outcomes compared to an approach based on routine preoperative imaging. Experienced surgeons can consider omitting preoperative imaging in patients without a history of neck surgery as this may reduce overall treatment costs.