OBJECTIVE Adrenal myelolipomas are rare benign non functioning tumors which are mostly detected incidentally by imaging (8-15%). The aim of this study was to find out the clinical outcome of 3 patients operated for incidentally discovered adrenal myelolipoma as well as to update the literature concerning this topic. METHODS During a 24 year period (1976-2000) we operated on 28 of 39 (72%) patients for incidentally discovered adrenal mass and pathology assessed 3 myelolipomas (11%). All patients were males and average age was 54.3 years (range 46-66). Myelolipoma was associated with arterial hypertension in 2 patients and BPH in 1. Patients underwent unilateral adrenalectomy. Results Myelolipomas, all unilateral, were right-sided in 2 cases (67%) and left sided in 1. Average tumor diameter, as detected by CT scan, resulted 10.3 cm range (3-17). Endocrine investigation was negative. Average tumor size, as detected by pathology, resulted 9.3 cm (range 3-14) and mean weight 653 gr (range 210-980). Histopathology assessed primary adrenal myelolipoma in all cases. Mean follow-up is 110.6 months (range 102-128) and all patients are alive and disease free. CONCLUSIONS Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are effective in diagnosing adrenal myelolipomas in about 90% of cases. Fine needle aspiration (FNA) cytology under CT or US control has an important role in investigating as well as diagnosing undefined masses suspected of adrenal or extraadrenal myelolipoma thus avoiding unnecessary surgery. The increasing number of incidentally discovered adrenal myelolipomas arise the question of appropriate treatment modalities which range from watchful waiting to surgical removal. Small asymptomatic tumors sized less than 4 cm can be monitored expectantly. Tumors when symptomatic or larger than 4 cm should be removed since the risk of spontaneous rupture with retroperitoneal hemorrhage and life threatening shock. Bilateral adrenalectomy for large and symptomatic tumors implies lifelong substitution with hydrocortisone. Actually, laparoscopic adrenalectomy is the new gold standard in treating myelolipomas since both showing more effective postoperative recovery than open surgery as well as reducing the number of patients who undergo long and close follow up.