Wilms tumor (WT) is the most common primary malignant renal tumor of childhood, accounting for 6% of all pediatric tumors, and represents one of the great success stories in pediatric cancer therapy. The paradigm for the treatment of a child with WT has evolved from a primary goal of survival alone to a risk-based approach. Unfortunately, despite 35 years of clinical trials by cooperative groups, bilateral WT (BWT) patients have not been formally studied. The most recent survival, rated for patients treated on National WT Study-5 with BWT, was 61-80.8% with favorable histology and 43.8% for a child with anaplastic or unfavorable histology. This article reviews outcomes and surgical considerations in the treatment of patients with synchronous BWT and proposes possible future directions in the treatment.