A man aged 61 years was diagnosed with a large 8.8 cm right renal mass after an episode of painless gross hematuria prompted emergency department evaluation. An MRI of the abdomen demonstrated right renal vein tumor thrombus and indeterminate 1-2 cm retroperitoneal lymph nodes. Chest imaging was negative for distant metastases. After extensive discussion, the patient elected to proceed with a right open radical nephrectomy with retroperitoneal lymph dissection for definitive management.

Figure 1. CT of the abdomen demonstrating a large central heterogeneous right renal mass and a 1.7 cm interaortocaval lymph node.
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