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Introduction and Objective: Definitive inclusion of renal mass biopsy (RMB) in small renal mass (SRM) diagnostic algorithm remains controversial. We assessed incidence and accuracy of RMB in SRMs in the CROES Renal Mass registry and the influence of preoperative RMB on perioperative complications after SRM nephron-sparing surgery (NSS). Materials and Methods: " ad hoc " description of incidence of preoperative RMB and characteristics of SRM cases with and without RMB. Accuracy of RMB was calculated in the SRM subcohort that received extirpative treatment and complication rate after NSS compared to between the two groups. Continuous variables were compared using t -test; categorical variables were compared using the chi-square test. K-statistics was used to analyze agreement between the biopsy histology and surgical pathology. Logistic regression was used to assess the association between RMB and NSS complications. All tests were two sided, and p -values <0.05 were considered statistically significant. Results: The rate of preoperative RMB in SRMs was 11.6% (175/1597) in Europe and the United States. RMB patients were more likely to have hypertension ( p  < 0.04), be on dialysis ( p  < 0.024), or smokers ( p  = 0.005), with multiple/bilateral tumors (0.008 and 0.010) and previous other malignancy ( p  = 0.021). They underwent radical nephrectomy more frequently than non-RMB group ( p  = 0.034). RMB was nondiagnostic in 16 cases (9%). Accuracy of RMB in distinguishing malignant from benign was 89.5%. Agreement between biopsy and final surgical pathology was 93% for malignant vs benign tumors (kappa = 0.655). Upstaging to pT3a occurred more frequently in the RMB group (12.6% vs 6.25% [ p  = 0.022]). Complication rate in renal mass-NSS subcohort was 15.8%, not statistically different between RMB and non-RMB groups. On logistic regression analysis, RMB was not associated with increased risk of postoperative complication after NSS (OR: 0.9, 95% CI: 0.43-1.89). Conclusion: The practice of RMB in SRM is still scarce despite high accuracy and concordance with final pathology. RMB does not seem to increase complication rate after NSS.