Despite the observed stage migration and earlier detection of renal masses, patients still present with locally advanced renal cell carcinoma. These patients represent a difficult oncologic challenge. Despite our ability to do surgical resectionto cure the disease, survival often remains limited. In this paper, we describethe role and indication for surgical resection for patients with enlarged retroperitoneallymph nodes, invasion of adjacent organs, invasion into the vena cavaor locally recurrent disease. The development of new strategies, including effective drugs to be used in association with surgical resection, will clearly be an essential step to further improve the outcome of these patients.