INTRODUCTION Techniques for the resection of renal tumours (RT) with extension to the inferior vena cava (IVC) are based on the experience of individual units. We attempt to provide a logical approach to the surgical strategies in a stepwise fashion. METHODS Over 6 years, 9 patients with RT invading the IVC underwent surgery. There were 6 males. The extension was at level IV in 3 and III in 6 cases. Cardiopulmonary bypass was used in 7 and hypothermia and circulatory arrest in 2 patients with level IV disease. The results and an algorithm of the plan of action in relation to the level of extension are presented. RESULTS Regarding postoperative morbidity, inotropic support was needed in 5 patients, a prolonged ICU stay in 3 (33.3%), tracheostomy in 1 (11.1%). Methicillin-resistant Staphylococcus aureus infection occurred in 1, sepsis in 2, cerebrovascular accident in 1. There were 2 deaths (22.2%). For level I-II disease there was no cardiothoracic involvement. For level III we used cardiopulmonary bypass and control of the cavo-atrial junction. For level IV or suboptimal thrombectomy of level III disease, we used brief periods of circulatory arrest and repair of the cavotomy with a pericardial patch. CONCLUSIONS Total clearance of the IVC from an adherent tumour is important for prognosis, therefore extensive level III and IV disease presents a surgical challenge. We recommend cardiopulmonary bypass for level III and brief periods of total circulatory arrest for level IV disease.