INTRODUCTION: The objectives were to: (1) analyze clinical and pathological features of renal cell carcinoma (RCC) with caval thrombosis in order to indentify independent prognostic factors, and (2) analyze perioperative morbidity and mortality. METHODS: The authors retrospectively analyzed clinical and pathological data of 56 patients treated for RCC with caval thrombosis during a 20-year period. The surgical procedure was essentially unchanged. Independent variables were: TNM, creatinine value, age, histological extent, histological type, adjuvant treatment, and surgical technique; the dependent variable was overall survival. Contingency and logistic regression tables were used. Kaplan-Meier method, log-rank, and Cox models were used to analyze survival rates. RESULTS: There were complications in 15 patients and 2 perioperative deaths. Overall mean (SD) survival rates were 32% (7%) and 24% (6%) at 3 and 5 years, respectively. Multivariate results showed that the significant prognostic indicators of survival were: the size of the tumor > 8 cm (P < .01), the presence of metastasis (P < .04), and lymph node invasion (P < .009). These were also regarded as the relevant variables, independent of patient survival. CONCLUSIONS: The surgical approach for this disorder is challenging and not exempt of complications. Nodal involvement, tumor size, and distant metastases are the most important prognostic factors; thrombus extension has a clear impact on surgical planning and performance.