Patients presenting with metastatic renal cell carcinoma (RCC) face a dismal prognosis, with a median survival time of only 6 to 12 months and a 2-year survival rate of 10% to 20%. RCC is notoriously chemorefractory, and immunotherapy is associated with total response rates of less than 20% and complete response rates of less than 5%. Therefore, surgery has continued to play a prominent role in the management of patients with metastatic RCC. Recent randomized prospective trials suggest a survival advantage for cytoreductive nephrectomy, and some patients with advanced RCC may also achieve palliation. Patients with limited and resectable metastases should be considered for combined nephrectomy and metastasectomy. The other main option for patients with advanced RCC is systemic immunotherapy followed by assessment for surgical consolidation, but responses in the primary tumor are uncommon and results with this pathway have not been encouraging. Tumor embolization can be a valuable palliative adjunct for some patients with metastatic RCC. Cytoreductive nephrectomy represents the most aggressive pathway for patients with metastatic RCC. Although cytoreductive nephrectomy can extend survival by approximately 50% for many patients, it can be associated with morbidity and delay in administration of systemic therapy. Therefore, patient selection, taking into account performance status and sites and burden of disease, which are well-established prognostic factors for patients with metastatic RCC, is of paramount importance in managing this challenging group of patients.