Background Renal vein and caval tumour extension occur in 10-25% of patients with renal cell carcinoma. This study aims to examine perioperative morbidity and survival outcomes after radical nephrectomy with inferior vena cava tumour thrombectomy at a quaternary institution in Australia. Methods This was a retrospective review of nephrectomy with tumour thrombectomy cases between June 2012 and 2022 at a single centre, followed up until September 2024. Overall survival (OS) was visualised by Kaplan-Meier plots and comparisons between survival by presence of metastases, margin status, and thrombus level (I-III vs IV) were explored with the log-rank test. Recurrence-free survival (RFS) in patients without initial metastases was also examined. Results We identified 39 patients, 25 (64%) were male and the median (IQR) age was 64 years (55–69). Metastatic disease was present in 14 patients (36%). 19 (49%) had level IV (supradiaphragmatic) tumour thrombus involvement. Six patients (15%) died in hospital, including two intraoperative deaths. A further 14 (36%) experienced Clavien-Dindo grade III or IV complications during their hospital stay. The median OS was 57 months (95%CI: 17–not reached). Excluding those who died in hospital, the median OS was 60 months (95%CI: 33–not reached). There was a significant difference in OS observed by presence of metastatic disease (p=0.003), but not with margin status (p=0.35) or thrombus level (p=0.22). The median RFS for M0 patients was 60 months (95%CI: 8–not reached). Conclusion While associated with high morbidity and mortality, nephrectomy and caval thrombectomy remains an effective treatment option for otherwise fatal advanced RCC.