Upper tract transitional cell carcinoma (TCC) arises from the renal pelvis, calices and ureters. These tumours are uncommon and constitute only 5% of TCCs of the entire renal tract (Campbell‐Wash 2003). TCCs of the renal pelvis account for 10% of all renal tumours and ureteric TCCs are even less common (El‐Fettouh 2002). Bilateral disease is extremely rare and occurs in 2% to 4% of the cases (Browne 2005). Although histologically similar to bladder TCCs, upper tract transitional cell carcinoma is more aggressive tumours with a tendency to multifocality, local recurrence and progression to an advanced stage (David 2002; Browne 2005; Muntener 2007).

The risk of upper tract TCCs increase with age and commonly occur between the sixth and seventh decade of life. Men have a two to three times more risk of developing upper tract TCCs as compared to women (David 2002; Campbell‐Wash 2003). Cigarette smoking is the most significant acquired risk factor for upper‐tract TCCs (Jensen 1988; McLaughlin 1992). Balkan endemic nephropathy (Petkovic 1975), analgesic abuse (particularly phenacetin) (McCredie 1982), exposure to chemical, petrochemical, aniline dye, coal, coke, tar, asphalt and plastic industry workers (Jensen 1988), chronic bacterial infection, and chemotherapy drugs (cyclophosphamide and ifosfamide), have all been implicated.

Upper tract transitional cell carcinoma is rarely asymptomatic. Frank or microscopic haematuria is the commonest presentation followed by loin pain (Campbell‐Wash 2003). Other clinical presentations include renal colic, palpable mass, weight loss, anorexia, and bone pain (Campbell‐Wash 2003).
Diagnosis is based on clinical, cytological, endoscopic and imaging grounds (Johnson 2005; Painter 2007). Useful imaging modalities include, retrograde pyelography, renal USS, CT and MR Urography (Browne 2005). Stage and grade at presentation dictate prognosis, with staging being the single most important prognostic indicator (Olgac 2004).

Open nephroureterectomy (ONU) has been the standard surgical option for upper‐tract TCCs with a normally functioning contralateral collecting system. The procedure itself consists of total nephrouretectomy with excision of the bladder cuff around the ureteric orifices to prevent tumour recurrence in the ureteric stump or around the ipsilateral ureteric orifice. The procedure entails either two long incisions or single long incisions for adequate exposure. As a result there is significant morbidity in the form post‐operative pain and therefore prolonged hospitalisation (Rassweiler 2004).
There has been considerable advancement in minimal invasive surgery in recent years to counter issues of post‐operative pain, prolonged hospitalisation associated with ONU. Some of the viable options include laparoscopic nephroureterectomy (LNU), ureteroscopic resection/fulgaration or percutaneous management.

Reports have proven that LNU that has reduced morbidity significantly as compared to ONU and the long term oncological efficacy of LNU are similar to ONU (David 2002; El‐Fettouh 2002; Bariol 2004; Rassweiler 2004; Arancibia 2007; Busby 2007; Muntener 2007). For these reasons LNU is steadily becoming the standard procedure of choice for upper tract TCCs especially bulky, large sized tumours in various centres.
With the recent development of sophisticated ureteroscopes, endoscopic management of low grade lesions measuring <1.5 cm with normal controlateral kidneys has been reported in various studies to be a very favourable option (David 2002; Johnson 2005; Soderdahl 2005; Mugiya 2006). However the need for long‐term surveillance and patient suitability are limiting factors .Laser therapy and electrocautery are the commonly used modes in these settings. Adjuvant topical therapy (mitomycin, BCG, etc) has been suggested to reduce recurrence of disease following endoscopic therapy (Keeley 1997).

Percutaneous approach combined with resection of the tumours has been suggested in some reports to be a useful option in low grade, large tumours (Jabbour 2000; Soderdahl 2005). For patients with solitary, bilateral tumours, severe renal insufficiency and severe co‐morbidities, partial nephrectomy, segmental ureteral resection with re‐anastomosis or ureteroscopic management, are surgical options. (Campbell‐Wash 2003; Johnson 2005).

Furthermore, there are various techniques described to deal with the lower end of the ureter during nephroureterectomy such as open excision, laparoscopic or endoscopic assisted methods. However there is no consensus on the best way to deal with lower end and surgical practice remains an issue of surgeon's preference and experience.