On the basis of tumor-specific findings and competing risks of mortality, all patients with a small renal mass should be considered for renal tumor biopsy when the results may alter management.

Active surveillance should be an initial management option for patients who have significant comorbidities and limited life expectancy. Qualifying statement: absolute indication: high risk for anesthesia and intervention or life expectancy <5 years; relative indication: significant risk of end-stage renal disease if treated, small renal mass (<1 cm), or life expectancy <10 years.

Partial nephrectomy for small renal masses is the standard treatment that should be offered to all patients for whom an intervention is indicated and who possess a tumor that is amenable to this approach.

Percutaneous thermal ablation should be considered an option for patients who possess tumors such that complete ablation will be achieved. A biopsy should be obtained before or at the time of ablation.

Radical nephrectomy for small renal masses should be reserved only for patients who possess a tumor of significant complexity that is not amenable to partial nephrectomy (PN) or where PN may result in unacceptable morbidity even when performed at centers with expertise. Referral to a surgeon and a center with experience in PN should be considered.

Referral to a nephrologist should be considered if chronic kidney disease (estimated glomerular filtration rate <45 mL/min/1.73m²) or progressive CKD develops after treatment, especially if associated with proteinuria.