The only possibility for cure in localized renal cell carcinoma (RCC) is surgery. Open radical nephrectomy (RN), as described by Robson, has long been the gold standard. Nevertheless, as a consequence of the increased use of abdominal imaging modalities, a continuing stage migration towards small, low-grade RCC lesions has become evident during the last decades. Together with this stage migration, nephron-sparing surgery (NSS), less-invasive therapies (laparoscopic RN and NSS), and minimally invasive therapies (radiofrequency ablation [RFA], cryoablation) have been developed and are gaining popularity. The value of laparoscopic RN and open NSS are acknowledged worldwide, but the value of laparoscopic NSS, RFA, and cryoablation remains to be established. Despite this evolution, there is still a place for open surgery for localized RCC. Open NSS is, at present, considered the standard of care for localized RCC less than 4 cm, while open RN still has a place for larger lesions, certainly when an extended lymph node dissection or adrenalectomy is warranted, or when a tumor thrombus is extending into the inferior vena cava. This review provides the data that support open surgery in clear, selected cases of RCC.