Kidney-sparing surgery (KSS) is used with increased frequency in non-muscle invasive, low-risk upper tract urinary cancer (UTUC), whereas radical nephroureterectomy (RNU) remains the gold standard in larger or advanced tumors. In case of kidney preservation, a differentiation between imperative and elective indications must be made. Furthermore, preoperative diagnostics such as imaging and endoscopic evaluation and patient-related risk factors such as urine cytology, tumor-localization, tumor size, and histopathology has a significant influence on the choice of therapy. The limited possibilities of pathological staging can be improved by new technological equipment and biomarkers. Depending on the risk stratification, the therapy can be carried out endoscopically, percutaneously, or by means of segmental ureter resection. According to the EAU guidelines, KSS is used especially for low-risk tumors. In selected cases and with imperative indications, organ preservation can also be performed in high-risk disease. All procedures require a complete resection of the tumor. After KSS, a stringent follow-up with regular radiological, cytological, and endoscopic investigations is necessary.