For many decades, radical nephrectomy (RN) has been the gold standard for the treatment of localized renal cell carcinoma (RCC). However, emerging evidence suggests that RN is a significant risk factor for the development of new-onset chronic kidney disease (CKD) or worsening of pre-existing CKD and leads to more cardiovascular events and worse survival [1–4]. Renal excision increases the risk factors for CKD by favoring arterial hypertension, proteinuria, hyperparathyroidism, anemia and metabolic acidosis. Patients are more likely to die of competing risks such as cardiovascular death than to die of the cancer itself. Owing to the higher risk of CKD following RN, the status of RN has been called into question. Other contributing factors are an increased incidental detection of small (<4 cm) renal masses with a significant proportion of benign tumors, the possibility of late recurrence of RCC in the contralateral kidney and the equal oncologic efficacy as partial nephrectomy (PN) for renal tumors less than 4 cm [5,6] and tumors between 4 and 7 cm [7,8]. A study in patients with localized RCC of 4 cm or less and a normal contralateral kidney showed that compared with PN, RN was associated with decreased overall survival (OS) in young patients (<65 years) with small renal masses .