Clinical stage I is the most frequent clinical presentation of non-seminoma testicular cancer. Despite a survival rate of close to 100%, the management of patients with this disease stage is controversial. The recurrence rate is 15% to 50% for those with stage I non-seminoma. A highly sensitive and specific biomarker that can predict or confirm relapse of disease, and help to drive a definitive risk-adapted management is still not available. Lymph Vascular Invasion (LVI) in the orchiectomy specimen has been used as a risk factor in patients with stage I non-seminoma, however, the discriminative power of LVI is modest at best. Presently there is no definitive biomarker that can predict a recurrence following a radical orchiectomy. In situations such as this, active surveillance of these patients helps avoid overtreatment in 50% to 85% of patients, with no risk of long-term side effects in non-relapsing patients and a preserved overall survival of almost 100% after specific treatment for recurrent disease. Although active surveillance has been accepted as the preferred option for stage I low-risk non-seminoma, its role in high-risk stage I non-seminoma remains controversial. Treating all patients with adjuvant chemotherapy following orchiectomy results in overtreatment of a significant proportion of patients. The challenge is in identifying the patient population that requires adjuvant chemotherapy and in determining how much chemotherapy to give to adequately reduce relapse risk. The role of RPLND in this group of patients too remains controversial. The relapse and complication rates of RPLND are significantly higher outside of expert surgical centres. Efforts need to be made to focus on maintaining cure rates and at the same time to minimize treatment-related long-term toxicity. Both the patient and the physician need to participate in the decision-making process, and management should be tailored to the individual patient’s needs and wishes.