Brief history: The patient is a 56-year-old male who was admitted to the hospital with “painless meatus hematuria for 20 days”. No other discomfort. He had previous hypertension for 1 year, which was well controlled. Physical examination: no positive signs. Physical status score was normal. CT and MRI: huge occupancy of the right kidney with cancerous thrombus in the right renal vein and inferior vena cava (figure below). Urine for tumor cells: normal. Renal dynamic imaging: right kidney function was impaired, left kidney function was normal. Under general anesthesia, right kidney cancer radical surgery + right renal vein and inferior strong vein cancer thrombus removal was performed. (see below) Postoperative pathology: papillary cell carcinoma of the right kidney with cancerous thrombus of the right kidney and inferior vena cava. Discussion: 1. Painless hematuria is not a unique symptom of uroepithelial carcinoma. When the kidney cancer invades the collecting system, hematuria may appear, but it appears later than uroepithelial carcinoma. 2.Imaging examination: When kidney cancer is large, it is often difficult to distinguish it from renal pelvis cancer in imaging examination. However, renal pelvic cancer rarely appears as renal vein and inferior vena cava cancer embolism. 3. Inferior vena cava cancer embolism is not a contraindication to surgery, especially in young patients. It can often be cured with preoperative and postoperative renal artery embolization and molecular targeting therapy. 4.Surgery of inferior vena cava carcinoma embolism is risky and difficult. It requires blocking the contralateral renal vein and the upper and lower ends of the inferior vena cava carcinoma embolism, and if the position of the carcinoma embolism is high, it requires blocking the hepatic vein and opening the chest if necessary. Full assessment before surgery, full preparation during surgery and close monitoring after surgery. 5. Select adjuvant therapy according to tumor pathological type after surgery, especially renal clear cell carcinoma, which is sensitive to molecular targeted therapy.