Surgery is the only curative treatment for localized renal cell carcinoma. Partial nephrectomy is the gold standard for the management of cT1 tumors whenever technically feasible since it achieves similar oncological outcomes and better preserves renal function compared to radical nephrectomy. Radical nephrectomy remains the mainstay of treatment for T2 tumors, although partial nephrectomy is increasingly performed. Active surveillance represents a suitable option for elderly and/or comorbid patients with incidentally detected small renal masses who have a low risk of cancer-specific mortality and significant competing-cause mortality. Thermal ablation may be offered in selected patients with small renal masses and should be discussed, particularly with elderly and comorbid patients who are unfit for surgery or patients with bilateral tumors or a solitary kidney. Percutaneous renal tumor biopsy should be increasingly used to histologically characterize small renal masses, especially when active surveillance or thermal ablation are considered. Properly performed renal tumor biopsies have low morbidity. a high diagnostic yield, and concordance with the pathology of the surgical specimen.