The incidence of small renal masses (< 4 cm) is increasing due to the widespread use of imaging studies. Many of these incidental lesions may remain asymptomatic or in fact be benign, and recent insight into their natural course has contributed to modifications in management. With improvements in biopsy technique and minimally invasive technologies, appropriate diagnosis and treatment of these masses are further being evaluated. Other contemporary approaches, including surveillance, laparoscopic partial nephrectomy, enucleation, ablative procedures, and high-intensity focused ultrasound, are weighed against open nephron-sparing surgery, the current gold standard for treatment. Here, we review currently available data on the efficacy of these treatment options. Additionally, we examine the natural history of small renal masses, the role of diagnostic biopsy, and follow-up strategies for proper management.