Background <p>Tumor-associated macrophages (TAMs) are linked with tumor progression in clear cell renal cell carcinoma (ccRCC), but the role of perinephric adipose tissue macrophages (PATMs) in ccRCC has not been elucidated. The aim of this study was to illustrate the association between PATMs and the prognosis of localized ccRCC.</p> Methods <p>A total of 135 consecutive patients who underwent radical or partial nephrectomy, with histopathologically confirmed ccRCC, from May 2018 to September 2019, were retrospectively enrolled. Macrophages in perinephric adipose tissue were detected by CD68 immunohistochemical staining. The density of PATMs was evaluated in relation to clinicopathological parameters and disease-free survival (DFS).</p> Results <p>We divided the patients into two groups according to the density of PATMs, 51 (37.8%) were identified as “PATMs-high”, and 84 (62.2%) were identified as “PATMs-low”. Patients with high PATMs density significantly correlated with male gender (<i>P</i> = 0.003), advanced T stage (<i>P</i> &lt; 0.001), higher rate of perinephric fat invasion (<i>P</i> = 0.006), more severe perinephric stranding (<i>P</i> &lt; 0.001), and higher MAP score (<i>P</i> = 0.014). Kaplan-Meier analysis demonstrated that high density of PATMs was significantly correlated with poor DFS (<i>P</i> &lt; 0.001). In multivariate Cox analysis, tumor size (HR: 1.241, 95% CI: 1.045–1.474, <i>P</i> = 0.014), MAP score (HR: 3.742, 95% CI: 1.698–8.248, <i>P</i> = 0.001), and PATMs density (HR: 3.011, 95% CI: 1.469–6.170, <i>P</i> = 0.003) were independent predictors of DFS in ccRCC.</p> Conclusions <p>PATM may serve as a novel prognostic predictor and potential therapeutic target in patients with ccRCC.</p>