Renal cell carcinoma with a thrombus limited to the trunk of the renal vein is quite different from renal cell carcinoma extending into the inferior vena cava. In the first case, the operative mortality is low, and the five year survival rate is about 53%. In the second case, surgery is difficult and the mortality is high; the gravity is directly related to the level of tumour thrombus involvement in the inferior vena cava; the proportion of cases with metastatic dissemination at the time of surgery is higher; the two year survival rate is 38.5% only. However, the long term survival rate of patients without metastasis and alive after surgical management, is equal in the two groups, about 60%. The prognosis of surgical treatment of renal cell carcinoma with massive extension high in the inferior vena cava would be improved by the optimal patient selection (patients without metastasis) and by the use of cardio-vascular surgical procedures (CEC).