Urothelial carcinoma of the upper urinary tract represents roughly 5–10% of all upper tract tumors. Of these tumors, approximately 75% will present confined within the renal pelvis. Historically radical nephroureterectomy has been the standard treatment in this patient population, but percutaneous tumor resection emerged over time as a suitable alternative. Initially reported as early as the 1980s, it provided a more minimally invasive and organ-sparing approach to upper tract urothelial carcinoma treatment. Over time as more data became available, equipment improved, and the technique itself was refined, percutaneous tumor resection developed into a conventional treatment modality with acceptable risk to patients. Data from several retrospective studies have shown that percutaneous tumor resection is best utilized in patients with low-grade, low-stage, and low-volume upper tract urothelial carcinoma. After decades of treatment, what is unclear is the effect that tumor location, patient gender, or adjuvant topical therapy may have on survival. What is not debated is that these patients must adhere to a strict follow-up schedule. Close surveillance is important since recurrence rates range from 23% to 41%, and 5-year survival rates range from 60% to 90% in T1 or carcinoma in situ disease to approximately 5% in T3 or worse disease. The percutaneous approach to upper tract urothelial carcinoma has became more internationally adopted as it has evolved, but radical nephroureterectomy is still advocated by many for the treatment of patients with multifocal disease or pT3 lesions to provide the highest likelihood of disease-free status. The percutaneous approach to upper tract urothelial carcinoma has continued to increase in popularity in appropriately selected patients and will likely continue to do so with improved instrumentation, technique, and patient outcomes.