Abstract Purpose Renal cell carcinoma (RCC) most commonly metastasizes to the lung. Preoperative indeterminate pulmonary nodules (IPNs) occur in half of patients with localized RCC; however clinical significance remains poorly defined. We aimed to determine whether IPNs, their size, or number, are associated with RCC outcomes. Materials and Methods Data of 1,102 patients with RCC who had chest computed tomography within 6 months before nephrectomy from 2002-2012 were reviewed. Patients with metastatic disease at presentation, benign tumors, pulmonary nodules >2cm, or concurrent pulmonary disease were excluded, leaving 748 for analysis. Study outcomes included lung metastases, any distant metastases, or death from RCC. Cox proportional hazards models were used to assess whether presence of IPNs, nodule size, or number were associated with outcomes. Models were evaluated by comparing discrimination using Harrell’s c-index. Results IPNs were present in 382/748 patients (51%). Median follow-up was 4.1 years (IQR, 2.2–6.1). Presence of IPNs was not associated with distant metastases or death from kidney cancer; however, compared to sub-centimeter IPNs, nodules >1cm were associated with metastatic disease after adjusting for tumor histology, stage, and size (HR=2.48; 95% CI, 1.08–5.68; p=0.031). C-indices for outcomes increased slightly after adding size of nodules to a predictive model adjusted for tumor characteristics. Conclusions In the current study, no evidence suggested IPNs <1cm were associated with RCC progression, although large nodules significantly predicted metastatic disease. Patients with sub-centimeter IPNs will unlikely benefit from extensive postoperative chest imaging surveillance, which should be reserved for patients with nodules >1cm.