Purpose: Adrenalectomy for primary aldosteronism (PA) lateralized to one gland yields significant biochemical cure rates, but clinical outcomes are less favorable, especially for patients with “non-classic” pathologies like multiple aldosterone producing nodules or hyperplasia. This study investigates why surgical results are poorer in “non-classic” PA, the ability of preoperative imaging to differentiate these, entities, and the existence of preoperative biochemical markers. Methods: The authors retrospectively reviewed 53 consecutive PA patients who underwent laparoscopic adrenalectomy at a tertiary care academic institution. Demographic data were collected and Statistical analyses compared pre- and post-operative blood pressure & antihypertensive medication use. Pathologic and radiographic results were examined by specialists. Results: Radiologically, “classic” and “non-classic” groups could not be distinguished. In the “classic” group, 95% achieved total cure and 57% showed improvement. Conversely, in the “non-classic group,” only 5% were cured while 43% improved. AVS data indicated that adenomas of the “classic” group secreted nearly twice the aldosterone as the “non-classic” group (8,074 vs. 4,423.5, P=0.02). The contralateral gland in the “non-classic” group secreted almost twice the aldosterone compared to the “classic” group though not statistically significant (419 vs. 273.3, P=0.1). Conclusion Patients with unilateral “non-classic” PA fare worse than those with unilateral “classic” PA after unilateral adrenalectomy. The non-classic variety may represent a form of asymmetrical bilateral hyperplasia. Cross table imaging is incapable of distinguishing between the 2 entities. AVS may identify non-classic unilateral PA and serve to address patient and physician expectations.