This paper is an analysis of 36 years of radical nephrectomy for renal cell carcinoma in the Mayo Clinic (1970-2006). In particular, it contains an analysis of the risk of renal fossa recurrence after nephrectomy (partial nephrectomies are not included) and attempts to identify risk factors. A total of 2502 patients were followed up for a median of nine years. A total of 33 patients (1.3%) developed ipsilateral renal fossa recurrence. The recurrences happened early, with a median time of 1.5 years after nephrectomy and usually carried a poor prognosis, with all patients dying within four years of recurrence (median 1.3 years). Many patients developed synchronous metastases elsewhere. As expected, high grade and stage were risk factors, as was the presence of coagulative necrosis. Interestingly, a surgically involved margin at the original nephrectomy was not identified as a risk factor. The recurrences were managed with either local management, systemic therapy or expectant management. Local management (excision, ablation, radiotherapy) carried the best prognosis. It must be borne in mind that the numbers of those treated with curative intent were very small (7 of 22) and many had synchronous metastases. In short, recurrence in the renal fossa is rare, carries a poor prognosis and the heterogeneity in disease volume make protocols and best practice difficult to standardise.