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Small renal masses (SRMs) are defined as radiologically enhancing renal masses of less than 4 cm in maximal diameter. The incidence of renal cell carcinoma (RCC) has increased in recent years, which is mainly due to the rise in incidental detection of lo-calized SRMs. However, the cancer-specific mortality rate is not increasing. This dis-crepancy may be dependent on the indolent nature of SRMs. About 20 % of SRMs are benign, and smaller masses are likely to have pathologic characteristics of low Fuhrman grade and clear cell type. In addition, SRMs are increasingly detected in elderly patients who are likely to have comorbidities and are a high-risk group for active treatment like surgery. As the information about the nature of SRMs is improved and management options for SRMs are expanded, the current role of renal mass biopsy for SRMs is also expanding. Traditionally, renal mass biopsy has not been accepted as a standard diag-nostic tool in the clinical scenario because of several issues about safety and accuracy. However, current series on SRM biopsy have reported high diagnostic accuracy with rare complications. Studies of modern SRM biopsy have reported diagnostic accuracy greater than 90 % with very high specificity. Also, current series have shown very rare morbid cases caused by renal mass biopsy. Currently, renal biopsy of SRMs can be rec-ommended in most cases except when patients have imaging or clinical characteristics indicative of pathology and in cases in which conservative management is not considered