Background <p>Upper tract urothelial carcinoma (UTUC) is a rare and aggressive malignancy. The standard treatment, radical nephroureterectomy (RNU), may lead to renal function deterioration in high-risk patients. Kidney-sparing surgery (KSS) offers an alternative, but its efficacy in high-risk UTUC, especially for high‐risk middle-lower ureteral urothelial carcinoma (UUC), is not well-established.</p> Methods <p>We conducted a retrospective analysis of 181 patients with high-risk middle-lower UUC treated between 2013 and 2023 at three hospitals in China. Patients were categorized into RNU (n = 155) and KSS (n = 26) groups. Propensity score matching (PSM) was used to balance baseline characteristics between groups. Perioperative outcomes and long-term survival were compared.</p> Results <p>After PSM, the KSS group showed significantly reduced surgery duration and blood loss compared to the RNU group. No significant differences were observed in transfusion rate, perioperative complications, resection margins, and hospitalization duration. In terms of prognosis, no significant differences were found in overall survival (OS), cancer-specific survival (CSS), intravesical recurrence-free survival (IVRFS), and metastasis-free survival (MFS) between the two groups post-PSM. Multivariate analysis identified T-stage as an independent risk factor for CSS.</p> Conclusion <p>KSS may be a feasible alternative to RNU in selected high-risk middle-lower UUC patients, with comparable long-term survival.</p>