OBJECTIVES: Surgical and non-surgical management options with pre-treatment biopsy are available for small renal masses (SRMs). The cost-effectiveness of these options is unclear. This study aimed to systematically review the cost-effectiveness of various management options for SRMs, and evaluate these cost-effectiveness studies. METHODS: A systematic literature review was conducted on five databases from inception to December 31, 2014. Search terms consisted of three categories of keywords, e.g., ‘economic evaluation’, ‘renal mass’ and ‘surgery’. Inclusion criteria were 1) original research, 2) full economic evaluation of management options for SRMs, 3) written in English, and 4) with targeted populations aged ≥ 18 years old. Exclusion criteria were 1) investigation of metastases only, and 2) case reports etc. Manual search of relevant bibliographies was performed. Eligible studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS: Among the 557 articles retrieved, 6 were included, all of which were cost-utility analyses and used Markov models with a lifetime horizon except for one study that adapted a 10-year horizon. One to three items on the CHEERS checklist were unfulfilled for each study. Three studies were from a societal perspective whereas the others were from a payer’s perspective. Health states included no evidence of disease, recurrence, metastases and death. Transition probabilities were obtained from observational studies. Evaluated strategies were surveillance, ablation, and partial and radical nephrectomy with/without pre-treatment biopsy. Two studies determined that pre-treatment biopsy was dominant while two studies found that laparoscopic partial nephrectomy was the optimal strategy. The remaining two studies concluded that ablation was preferred. CONCLUSIONS: The evidence of cost-effectiveness of management options for SRMs is limited. The findings of the available studies are inconclusive. Large, prospective, randomized clinical trials assessing various competing strategies in the management of SRMs are needed to inform better decision-making for physicians and patients.