Purpose of Review <p>This review aims to critically evaluate the evolving role of minimally invasive surgery (MIS) in the nephron-sparing management of renal tumors in patients with a solitary kidney. We sought to assess current evidence regarding surgical approaches, ischemia strategies, oncologic and functional outcomes, and to identify key determinants guiding surgical decision-making in this high-risk population.</p> Recent Findings <p>Recent literature exhibits a progressive shift toward minimally invasive approaches, without compromising oncologic or long-term functional outcomes. Accumulating evidence highlights preserved renal parenchymal volume and baseline renal function as the primary predictors of postoperative renal recovery, whereas ischemia type and time mainly affect early postoperative function. Advanced technologies, including 3D modeling, may further optimize selective clamping and perioperative outcomes in selected cases.</p> Summary <p>Partial nephrectomy remains the mainstay of treatment for renal tumors in solitary kidneys. Surgical approach selection should be individualized, driven by tumor complexity and renal function rather than technique alone. Referral to high-volume centers and continued refinement of MIS are essential to optimize outcomes and guide future research in this challenging clinical setting.</p>