The standard practice for testicular masses confirmed on ultrasound has been to offer an inguinal orchidectomy, on the presumption that the mass represents testicular cancer. The growing use of scrotal ultrasound for various indications has led to an increase in the detection of small testicular masses (STM), but there is no consensus on the definition of these, usually somewhere <2.5 cm diameter. In this retrospective multicentre study from Italy, 147 men who had a STM <2 cm diameter on ultrasound underwent testis sparing surgery (TSS), with frozen section examination followed by formal histopathology review at a regional referral centre. Twenty-one (14%) men were confirmed to have testicular cancer, all classic seminoma pT1. Intratubular germ cell neoplasia unclassified (ITGCNU) was associated with seminoma in 88.2%; in all these cases a radical orchidectomy was performed. Eighty-five men had a lesion <1cm, in which group six (7%) had testicular cancer. On multivariate analysis only the preoperative diameter was a predictor of malignancy, and the risk of malignancy increased sevenfold with each mm increase in diameter. The non-malignant lesions included 108 (74.3%) benign tumours and 18 (12%) benign lesions; the former category included Leydig cell tumour, Leydig cell hyperplasia, dermoid cyst, Sertoli cell tumour, tunica vaginalis adenomatoid tumour, epidermoid, etc. whereas the latter included (surprisingly) normal testicular parenchyma, testicular atrophy, haematoma, abscess and inflammatory infiltrates. TSS is recommended in the guidelines for specific circumstances, such as bilateral synchronous tumours and a tumour in a solitary testis comprising <30% of testicular volume, but is not standard practice for STMs in men with a normal contralateral testis, but this study highlights the benign nature of many small masses. This study has some obvious limitations; apart from its retrospective nature, the follow-up duration is short considering that Leydig cell tumour metastases has been described eight years after, and the accuracy of ultrasound was far from perfect so will need further validation.