Cytoreductive nephrectomy prior to cytokine therapy has a well-established role in the treatment of appropriately selected patients with metastatic renal cell carcinoma (RCC). Recent use of novel molecular targeted agents in the management of metastatic RCC has challenged the current dogma of treatment with regards to the necessity, patient selection for and timing of cytoreductive nephrectomy. Current evidence suggests that cytoreductive nephrectomy still plays an integral part in the multimodal paradigm of management for metastatic RCC. This review highlights the role of cytoreductive nephrectomy, and discusses controversial issues surrounding cytoreductive nephrectomy in the treatment of metastatic RCC, in the context of immunotherapy and also in the new era of targeted therapy. It also gives updates on the changing concepts of surgical approaches to cytoreductive nephrectomy in metastatic RCC.