Upper tract urothelial carcinoma (UTUC) is a relatively uncommon but highly aggressive malignancy of the urothelial tract. Radical nephroureterectomy has traditionally been regarded as the standard treatment. However, this procedure inevitably results in loss of functional renal units and is associated with an increased risk of chronic kidney disease and related complications. With continuous advances in imaging modalities, endoscopic technologies, and risk stratification systems, kidney-sparing treatment has gradually evolved from a "passive alternative" into an evidence-based therapeutic strategy for selected patient populations. In recent years, beyond conventional kidney-sparing approaches such as endoscopic ablation and segmental resection, novel multimodal strategies integrating perioperative systemic therapy-particularly antibody-drug conjugates combined with immunotherapy-with local treatment have emerged. These approaches offer new possibilities for achieving oncologic control while preserving renal function in selected patients with high-risk UTUC. This review summarizes current domestic and international evidence on kidney-sparing management of UTUC, with a focus on risk stratification, major technical approaches, recent advances, and existing limitations.