Synchronous bilateral Wilms tumor is rare (5 - 10% of cases) but well recognized, conferring a worse prognosis as surgical excision is much more difficult.  Emphasis is now on neoadjuvant chemotherapy followed by surgery for residual masses.  As far as staging goes, it is described as stage V irrespective of the local staging of each tumor mass.  Presentation is typically delayed as children are asymptomatic. Parental palpation of a mass is the usual scenario.