The presence of image‑defined risk factors (IDRF) in neuroblastoma plays a large role in decision making for primary resection versus neoadjuvant chemotherapy. This study investigates how the number and type of IDRFs affect surgical outcomes for primary resection of neuroblastoma. A retrospective review was performed including patients diagnosed with neuroblastoma with at least one IDRF who underwent primary resection of their tumor between 2003 and 2017. Cross sectional imaging was reviewed by a single pediatric radiologist for determination of IDRFs. Surgical outcomes were compared by <5 versus ≥5 IDRFs and vascular or non‑vascular involvement. A total of 28 patients were included in the study, 18 with <5 IDRFs and 10 with ≥5 IDRFs. Fifteen patients had vascular involvement and 13 did not. Nine were adrenal, 6 were cervicothoracic, and 5 were abdominal non-adrenal. Patients with ≥5 IDRFs were found to have an increased rate of complications (40% vs 0%; p<0.01), operative time (318 vs 148 min; p<0.01), estimated blood loss (187 mL vs 45 mL; p<0.01), length of stay (9.6 vs 4.9 days; p<0.01), and hospital readmission (20% vs 0%; p = 0.04). No differences were found in degree of resection (p = 0.06). All complications occurred with vascular involvement IDRFs compared to non‑vascular IDRFs (27% vs 0%; p = 0.04). The presence of ≥5 IDRFs and vascular involvement increases complications associated with primary resection of neuroblastoma. Our findings underscore the importance of neoadjuvant chemotherapy prior to resection. Further studies are required to determine how different IDRFs influence surgical risk.