In all, 4–10% of tumor thrombus in renal cell carcinoma (RCC) extends into the inferior vena cava (IVC). When the thrombus extends into the right atrium (RA), it becomes surgically challenging; and depending on its extension and adherence to the underlying structure, it may need cardiopulmonary bypass (CPB). The utility of transesophageal echocardiography (TEE) is reviewed for the management of RCC with cavoatrial extension. Intraoperative TEE is an essential modality in cases of RCC with level IV tumor thrombus, and in cases that require CPB with or without deep hypothermic circulatory arrest (DHCA). Intraoperative TEE provides us real-time information about thrombus staging in addition to the properties of the thrombus, such as adherence and fragility. Intraoperative TEE can also be used to assess cardiac function, fluid status, real-time monitoring of thrombus including embolization while manipulation and to ensure no residual thrombus. We therefore recommend the use of intraoperative TEE in RCC with level IV tumor thrombus. In the future, more research is needed to demonstrate the impact of intraoperative TEE on morbidity, mortality, and complication rate of the procedures.