This study aimed to determine whether active ultrasound surveillance may obviate the need for surgical resection in selected patients with small testicular lesions (STLs). A retrospective 11-year review was conducted of adults who were diagnosed with an STL on scrotal ultrasonography and who either had orchiectomy or sonographic follow-up during a period of at least 3 months. A total of 101 subjects were enrolled. Ultrasound findings, clinical features, histopathology/follow-up imaging were recorded. Logistic regression analysis was performed to select independent risk factors for the diagnosis of malignancy. Seventeen (16.8%) subjects underwent immediate surgery, 8 (7.9%) of 101 underwent surgery after ultrasound follow-up, and 76 (75.3%) of 101 were followed with ultrasound only. The follow-up period ranged from 1 to 7 months in the 8 patients who ultimately underwent surgery after ultrasound follow-up and from 6 to 84 months in the 76 patients followed up with ultrasound only. All 15 malignant cases underwent immediate surgery without follow-up sonography. The frequency of lesions, either benign at surgery or stable on ultrasound, was 85.1% (86 of 101; 95% confidence interval, 77%–91%). Logistic regression analysis showed that lesion size was the only independent risk factor for malignancy in hypoechoic STLs (P < 0.05). Most of the STLs were stable on serial sonograms and likely benign. Active ultrasound surveillance may be an appropriate management strategy in patients with STLs.