Renal cell carcinoma (RCC) has a natural tendency to involve the venous system with formation of a tumor thrombus in renal vein and inferior vena cava (IVC). The presence of venous involvement significantly worsens the prognosis of patients with RCC. Surgery remains the most effective method of treatment but maybe, in cases of extended IVC thrombosis, a challenge for urologists. Complete removal of all tumor is the major goal of surgery which provides satisfactory long-term survival and must be attempted whenever possible. Several surgical techniques have been proposed but all are associated with a high rate of perioperative complications and mortality. Minimally invasive approaches including laparoscopy and robotic surgery are mainly applicable for less extended IVC thrombi, while open surgery remains the gold standard for this category of patients. Most IVC thrombi can be managed without the use of circulatory support by using different methods of IVC control depending on the thrombus level. However, cases of bulky intraatrial thrombi may require use of cardiopulmonary bypass with or without cardiac arrest and hypothermia. Selected patients with an IVC thrombus and solitary or oligo-distant metastasis may also be considered for cytoreductive procedures after discussion in a multidisciplinary tumor board and weighting the benefits against risks of thrombectomy.