Adrenocortical carcinoma (ACC) is an aggressive cancer, and comprehensive preoperative assessment, including imaging and staging, is essential to determine the feasibility of a minimally invasive approach. Posterior retroperitoneoscopic adrenalectomy (PRA) has emerged as a valuable surgical approach for managing different adrenal pathologies, as it maximizes the current advantages of the minimally invasive technique such as a shorter operative time, less pain, and a shorter hospital stay. However, selection of the best surgical treatment for ACC should be individualized based on factors like tumor size and stage of the disease, and it often requires a multidisciplinary approach involving surgeons, oncologists, and endocrinologists to optimize the outcome and follow-up care. While the surgical management of ACC necessitates en bloc oncological removal of the tumor with the retroperitoneal fatty tissue, PRA can be proposed for selected patients as it offers a direct approach to the retroperitoneum. In this chapter we describe the potential indications and the surgical technique for PRA in the treatment of ACC.