We report a rare case of virilizing adrenal cancer with tumorous invasion of the left renal vein in which a retroperitoneal adrenalectomy with bail-out nephrectomy was performed. A tumor thrombus infiltrated the wall of the left adrenal vein and extended into the left renal vein. Initially, a kidney sparing procedure with partial tangential excision of the involved renal vein wall was performed. After positive vein margins were confirmed with intraoperative histology, the indication for nephrectomy was made. To the authors’ awareness, this is the first report of a virilizing adrenal cancer with a tumor thrombus infiltration of the renal vein and surgical tendency for kidney preservation.