Purpose: To assess nationwide the pathologic characteristics and trends in type of surgery and pathologic reporting in surgically managed renal tumors =4cm. Materials and Methods: A review of all pathologic reports of primary small renal masses operated on in the Netherlands during the period 1995 to 2005 was performed. The data source was a nationwide central archive of histocytopathology (Patologisch Anatomisch Landelijk Geautomatiseerde Archief). Tumors were stratified into three groups: =2, 2.1 to 3.0, and 3.1 to 4.0cm. Age, sex, type of operation, and tumor pathology were analyzed. For renal-cell carcinomas, grade (3-tiers Fuhrman) and stage (2002 Tumor, Node, Metastasis) were assessed. Trends in type of surgery (radical or partial nephrectomy [PN]) and pathologic reporting during the study period were analyzed. Results: Of all operated primary kidney tumors, 25.3% were =4.0cm. The mean age of the patients was 63.1 years (standard deviation 11.7), and the male/female ratio was 3:2. Only 7.5% were benign tumors, and 9.8% were locally advanced (=T3). Tumors =3.0cm were more likely to be benign (P=0.006) and of lower stage (P=