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Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?Active surveillance of small renal masses has traditionally been reserved for elderly patients deemed unfit for surgery or ablation. There is increasing evidence showing the safety of active surveillance in the management of small renal masses.In this retrospective study we compared outcomes for patients with small renal masses managed with active surveillance, radical nephrectomy and partial nephrectomy. We showed that active surveillance was safe and appeared as effective as immediate surgery in the management of small renal tumours.To compare the oncological outcomes of active surveillance (AS), radical nephrectomy (RN) and partial nephrectomy (PN) in the management of T1a small renal masses (SRMs).At present AS is used in the treatment of SRMs in elderly patients with multiple co-morbidities or in those who decline surgery.We identified all patients with T1a SRMs managed with RN, PN or AS.Retrospective data were collected from patient case records with survival data and cause of death cross-referenced with the Oxford Cancer Intelligence Unit.A total of 202 patients with 234 T1a SRMs (solid or Bosniak IV) were identified; 71 patients were managed with AS, 41 with an RN and 90 by PN.Over a median follow-up of 34 months the mean growth rate on AS was 0.21 cm/year with 53% of SRMs managed with AS showing negative or zero growth.No statistically significant difference was observed in overall (OS) and cancer-specific (CSS) survival for AS, RN and PN (AS-CSS 98.6%, AS-OS 83%; RN-CSS 92.6%, RN-OS 80.4%; PN-CSS 96.6%, PN-OS 90.0%).Active surveillance of SRMs offers oncological efficacy equivalent to surgery in the short/intermediate term.The results of this study support a multicentre prospective randomized controlled trial designed to compare the oncological efficacy of AS and surgery.