We reviewed the role of transesophageal echocardiography (TEE) in the management of renal cell carcinoma (RCC) with associated tumor thrombus. Many consider intraoperative TEE as imperative in cases of Level 4 thrombi with atrial involvement, as well as in cases that require the use of cardiopulmonary bypass (CPB). However, the role of TEE in the surgical management of RCC with associated inferior vena cava (IVC) thrombus may expand beyond this subset. When performed after induction, TEE provides updated information regarding tumor thrombus staging, which is essential for optimal surgical planning. Furthermore, TEE provides feedback regarding properties of the thrombus, such as fragility and adherence, which may alter surgical technique. TEE can also be used intraoperatively for central venous line placement, to monitor cardiovascular and fluid status, to guide vascular clamp placement, and to ensure complete removal of the tumor thrombus. In some cases, the use of TEE allows for less morbid procedures and safe avoidance of CPB. We therefore recommend the use of preoperative TEE in all cases with a known tumor thrombus with discretion as to what extent TEE is used throughout the remainder of the case. Further investigation is necessary to elucidate the effect of TEE on patient outcomes, including surgical complication rates, morbidity and mortality of procedures, and cancer control.