Kidney-Sparing Approaches in Upper Tract Urothelial Cancer: A Narrative Review

Upper tract urothelial carcinoma (UTUC) is a relatively rare neoplasm. Historically, radical nephroureterectomy (RNU) has been the gold-standard treatment; however, its association with postoperative renal dysfunction and reduced quality of life has driven a paradigm shift toward kidney-sparing surgery (KSS). This literature review synthesises late evidence regarding nephron-sparing techniques for UTUC, such as endoscopic ablation, segmental and total ureterectomy and novel minimal invasive modalities. Clinical, radiologic, and molecular parameters are examined in order to refine risk stratification, which is crucial for selecting appropriate patients who may benefit from KSS. Even though endoscopic ablation is associated with higher local recurrence rates, it demonstrates comparable cancer-specific and overall survival to RNU in low-risk UTUC and selected high-risk patients. Segmental and total ureterectomy, if technically feasible, accomplish similar oncologic outcomes with RNU and are superior regarding renal function preservation. Novel kidney-sparing therapies such as intraluminal chemoablation with UGN-101 and vascular-targeted photodynamic therapy show encouraging efficacy and safety in early trials. Perioperative chemotherapy and immunotherapy may expand the indication for kidney-sparing approaches in the near future, combined with emerging biomarker-driven models such as the aristolochic acid (AA) mutational signature. Despite these advances, long-term oncologic outcomes, optimal adjuvant regimens, and molecularly guided treatment algorithms remain incompletely defined. In order to verify oncologic efficacy, systematise follow-up protocols, and establish personalized therapeutic pathways guided by molecular patterns, future multicenter prospective studies are essential.