The incidence of renal cell carcinoma continues to rise because of increased imaging utilization with the majority of new cases being lower stages based on size criteria. The incidence of larger renal tumors with known propensities for venous thrombus formation is still present and remains a challenge for the urological community in terms of surgical treatment with acceptable oncological outcomes and limited complications. Proper staging and preoperative imaging are crucial to determine the best approach with limited morbidity. As previously described by multiple authors and institutions, the level of tumor thrombus is one if not the most important factor in determining the surgical approach. We detail our surgical approach and surgical technique in great detail with respect to the thrombus within the renal vein, extending into the inferior vena cava or ending in the right atrium or ventricle. This chapter also provides data and technical descriptions from our experience and that of contemporaries at other institutions describing alternative approaches. This latter section can be of importance during any surgical procedure in which unanticipated complications can arise. We have also included our own personal experience with this patient population, which represents one of the largest known within the global urological community.