Approximately 4% to 10% of patients with renal cell carcinoma (RCC) present with vascular tumor thrombus. Often, these patients also present with metastatic disease. This study examined the clinical outcome and morbidity of patients with RCC and vascular tumor thrombus treated with aggressive surgical therapy. From 1989 to 2006, 118 patients were identified with Stage pT3b or pT3c RCC who had undergone radical nephrectomy and thrombectomy. Disease-specific survival (DSS) and overall survival were measured by Kaplan-Meier statistics with the log-rank test to assess differences in survival stratified by the clinical and pathologic variables. Cox regression techniques were used to identify significant predictors of DSS. The median follow-up was 18 months (range 1 month to 13.55 years). Tumor thrombus was at the level of the renal vein in 67 patients (56.8%), the infradiaphragmatic inferior vena cava in 39 (33%), and the supradiaphragmatic inferior vena cava in 12 patients (10%). Of the 118 patients, 42 (35.6%) presented with metastasis. The median tumor size was 8.2 cm. The 5-year overall survival rate was 40.7%. The 5-year DSS rate was 60.3% in those without metastasis and 10% in those with metastasis (P <0.001). The level of tumor thrombus did not significantly affect survival (P = 0.85). When the patients without metastasis were analyzed separately, nodal positivity (P = 0.03) and a tumor diameter greater than 7 cm (P = 0.05) were significant predictors of DSS. Our results support the role of radical nephrectomy and thrombectomy in patients with RCC and vascular tumor thrombus. The absence of significant morbidity makes aggressive radical surgery feasible in the patients with tumor thrombus and metastatic disease. The current TNM staging system may need to be revised, given the evidence that the level of tumor thrombus invasion does not affect the survival outcomes.