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The kidney is one of the most complicated organs in development and is susceptible to more types of diseases than other organs. The disease spectrum includes developmental and cystic diseases, involvement by systemic diseases, iatrogenic complications, ascending infections and urinary tract obstruction, and neoplastic diseases. The diagnosis of kidney disease is unique involving 2 subspecialties, urologic pathology and renal pathology. Both renal and urologic pathologists employ the renal biopsy as a diagnostic modality. However, urologic pathologists commonly have a generous specimen in the form of a nephrectomy or partial nephrectomy while a renal pathologist requires ancillary modalities of immunofluorescence and electron microscopy. The 2 subspecialties differ in the disease spectrum they diagnose. This separation is not absolute as diseases of one subspecialty not infrequently appear in the diagnostic materials of the other. The presence of medical renal diseases in a nephrectomy specimen is well described and recommendations for reporting these findings have been formalized. However, urologic diseases appearing in a medical renal biopsy have received less attention. This review attempts to fill that gap by first reviewing the perirenal anatomy to illustrate why inadvertent biopsy of adjacent organs occurs and determine its incidence in renal biopsies followed by a discussion of gross anatomic features relevant to the microscopic domain of the medical renal biopsy. Unsuspected neoplasms and renal cysts and cystic kidney diseases will then be discussed as they create a diagnostic challenge for the renal pathologist who often has limited training and experience in these diseases.