Background An objective of the Children's Oncology Group AREN0534 Study was to improve the survival of patients with bilateral Wilms tumors (BWT) by using preoperative chemotherapy of limited duration and tailoring postoperative therapy based on histopathologic response. The authors report outcomes based on postoperative histopathologic responses. Methods Patients with BWT received treatment with vincristine, dactinomycin, and doxorubicin for 6 or 12 weeks followed by surgery. Postoperative therapy was prescribed based on the highest risk tumor according to the International Society of Pediatric Oncology classification and the Children's Oncology Group staging system. Results Analyses were performed on data from 180 evaluable children. The 4‐year event‐free survival (EFS) and overall survival (OS) rates were 81% (95% CI, 74%‐87%) and 95% (95% CI, 91%‐99%), respectively. Seven patients who had completely necrotic tumors had a 4‐year EFS rate of 100%. Of 118 patients who had tumors with intermediate‐risk histopathology, the 4‐year EFS and OS rates were 82% (95% CI, 74%‐90%) and 97% (95% CI, 94%‐100%), respectively. Fourteen patients who had blastemal‐type tumors had 4‐year EFS and OS rates of 79% (95% CI, 56%‐100%) and 93% (95% CI, 79%‐100%), respectively. Eighteen patients who had diffuse anaplasia had 4‐year EFS and OS rates of 61% (95% CI, 35%‐88%) and 72% (95% CI, 47%‐97%), respectively; and the 4‐year EFS and OS rates of 7 patients who had focal anaplasia were 71% (95% CI, 38%‐100%) and 100%, respectively. There was no difference in the outcomes of patients who had different histopathologic subtypes within the intermediate‐risk group (P = .54). Conclusions A risk‐adapted treatment approach for BWT results in excellent outcomes. This approach was not successful in improving the outcome of patients who had diffuse anaplasia. A risk‐adapted treatment approach for bilateral Wilms tumors resulted in excellent outcomes. Patients who had blastemal‐predominant histopathology appeared to have an improved outcome.