The diagnosis and treatment of kidney cancer continues to evolve with advances in imaging and surgical approaches. The use of nephron sparing surgery (NSS) has become the operation of choice for treating small renal masses. Yet, technical difficulty and a variety of approaches have left debate for best method in the overweight population. This review summarizes the current knowledge in the open, laparoscopic, and robotic approaches to identify key risk factors, general assessments, complication rates, and the influence of body habitus for each approach.