INTRODUCTION AND OBJECTIVES Concurrent adrenalectomy during renal surgery for RCC was once routine. More recent data suggest that adrenalectomy should be reserved for tumors ≥7cm, particularly those involving the upper pole. We evaluated the radiographic and pathologic incidence of adrenal involvement in patients undergoing renal surgery for RCC ≥7cm. METHODS Patients undergoing renal surgery for tumors ≥7cm between 1999 and 2008 were identified from our kidney cancer registry. Fisher’s exact test was used to determine whether radiographic tumor location predicted adrenal involvement. Kaplan-Meier method and Cox proportional hazard regression models were used to analyze the impact of adrenal resection on outcome. RESULTS Of 1,650 patients, we identified 179 patients who underwent surgery for RCC ≥7 cm. Of these 91 underwent concurrent total ipsilateral adrenalectomy at the time of renal surgery with pathological adrenal involvement confirmed in 4.4% (4/91). Upper pole location did not predict involvement (p=0.83). Preoperative adrenal imaging was 100% sensitive and 92% specific for detection of adrenal involvement by RCC with a 100% NPV. No survival advantage was noted on multivariable analysis comparing those who underwent adrenal resection to the cohort (n=88) whose adrenal was spared (p=0.38). CONCLUSIONS Synchronous ipsilateral adrenal involvement with RCC is rare, even in cases of large and/or upper pole tumors making routine adenalectomy unnecessary. Pre-operative adrenal imaging is highly sensitive and should inform the decision regarding adrenalectomy more than tumor size or location.

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