PURPOSE OF REVIEW: Small renal masses are increasingly being discovered incidentally on routine abdominal imaging performed for other purposes. The natural history of small renal masses as well as the therapeutic approach for such lesions is an evolving paradigm. In this review, we assess the current literature regarding this controversial topic. RECENT FINDINGS: Nephron-sparing surgery can be performed with minimal morbidity and mortality. Ablative techniques, such as cryoablation and radio frequency ablation, have shown both safety and reliability in series reporting short-term oncologic follow-up. Preliminary studies seem to favor cryoablation when compared with radio frequency ablation. Observational series have shown that very few of these selected patients present disease progression while on active surveillance. Finally, recent studies have shown that renal biopsy is both well tolerated and accurate. SUMMARY: The management of small renal masses remains a challenging issue. Although nephron-sparing surgery is the standard of care for these masses, ablative techniques and observation represent adequate alternatives, especially for poor surgical candidates. Renal biopsy is increasingly proving to be of value in the management of small renal masses.