Objective: Autonomous cortisol secretion (ACS) in the adrenal incidentaloma (AI) refers to an excess of low-grade autonomous cortisol without the clinical symptoms of Cushing’ssyndrome (CS), while ACS is shown to be related to the accumulation of visceral fat. To elucidate whether the accumulation of fat in different compartments, such as total adiposetissue (TAT), peritoneal adipose tissue (PAT), retroperitonealadipose tissue (RPAT), and subcutaneous adipose tissue(SAT) could predict metabolic problems in patients with ACS.Material and Methods: We conducted a retrospective cohort study, including 74 patients diagnosed with ACS and 8patients diagnosed with CS. 8 patients with ACS had also undergone adrenalectomy. Baseline (initial admission) and follow-up (most recent visit) data, including the clinical,laboratory, and radiological parameters, were evaluated. Results: Total adipose tissue (TAT), visceral adipose tissue(VAT), PAT, and RPAT increased significantly while the SATremained stable in patients with ACS. Adrenalectomy in patients with CS resulted in a significant reduction of TAT, VAT,PAT, and RPAT while SAT was relatively preserved. However,no significant change was observed in surgically treated patients with ACS. The independent predictors of cardiovascular events, glucose intolerance, or elevated blood pressurewere age, the level of cortisol post dexamethasone suppression test (DexF), and an increase in the RPAT. Conclusion:Visceral fat accumulation, particularly in the retroperitonealarea, slightly contributed to the development of metabolicproblems in patients with ACS.