OBJECTIVES To evaluate the impact of cancer-associated symptoms present at the diagnosis of renal cell carcinoma (RCC) on the prognosis of patients. Increasing numbers of RCC are currently detected incidentally by routine ultrasonography. METHODS From January 1994 to December 2000, 693 operations for RCC in 683 consecutive patients have been performed at our institution. Overall, tumor-specific, and progression-free survival were investigated using the Kaplan-Meier method. For multivariate analysis regarding tumor-specific survival, the Cox regression model, including risk ratios, was used. A receiver operating characteristics curve regarding the sensitivity and specificity for the association between tumor size and symptoms was used. RESULTS Of the 683 patients, 417 patients were male and 266 female. The mean patient age was 62 years (range 16 to 88). Of the 683 patients, 141 (20.8%) presented with symptoms suspicious for cancer. The 5-year overall, progression-free, and cancer-specific survival rates were 82%, 79%, and 86%, respectively, for asymptomatic patients compared with 60%, 55%, and 65%, respectively, for patients with symptoms at diagnosis (P <0.0001, log-rank test). The cutoff value of 5 cm for the tumor diameter to result in symptoms was chosen on the receiver operating characteristic curve. Multivariate analysis found tumor grade (P = 0.001), tumor stage (P = 0.001), presence of symptoms (P = 0.013), and tumor diameter (P = 0.005) to be independent prognostic parameters for cancer-specific survival. CONCLUSIONS Tumors larger than 5 cm were significantly more likely to cause symptoms compared with smaller tumors in our series. In multivariate analysis, patients presenting with symptoms suspicious for cancer at the diagnosis of RCC had a 1.8-fold greater risk of dying of cancer compared with patients without symptoms.