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With this review, we describe the most recent advances in active surveillance as well as diagnosis and management of small renal masses (SRMs).We discuss diagnosis, differentiation of solid from cystic lesions, risk prediction and treatment of the SRM. A better understanding of the disease facilitates the use of more conservatory treatments, such as active surveillance. Active surveillance has been increasingly accepted not only for SRM, but also for larger tumors and even metastatic patients. Exiting advances in risk prediction will help us define which patients can be safely managed with active surveillance and which require immediate treatment. Meanwhile, the use of renal tumor biopsies is still an important tool for these cases.Active surveillance is an option for many patients with renal masses. Noninvasive methods for diagnosis and risk prediction are being developed, but meanwhile, renal tumor biopsy is a useful tool. A better understanding of the disease increases the number of patients who can undergo active surveillance fully certain of the safety of their management.