Renal preservation procedures have now become widely accepted for most renal masses, particularly renal masses <4 cm. This shift in the treatment paradigm is primarily due to our improved understanding of the tumor biology, and advances in radiologic imaging and surgical technology. The increased utilization of cross-sectional imaging, such as CT and MRI, has resulted in an increased incidence of small renal masses (SRMs) < 4 cm. In turn, the less-invasive nephron-sparing techniques such as laparoscopy and ablation have been employed to reduce the morbidity of the traditional open nephrectomy. The conventional and robotic-assisted laparoscopic partial nephrectomy is now considered a standard treatment for SRMs <4 cm. Techniques in patient positioning, access selection, hilar clamping, and tumor resection vary from surgeon to surgeon. Complications such as pseudoaneurysms and urine leaks remain postoperative risks despite improvement in technique. Other treatment modalities such as ablative therapy are beginning to gain ground but have not become the mainstream treatments. Furthermore, the use of renal mass biopsy may shape future guidelines for personalized SRM management. Finally, future developments in imaging technology may facilitate the identification and isolation of the safest surgical approach to an SRM.