OBJECTIVES: Several series have demonstrated the effective management of low-grade upper tract urothelial carcinoma (UC) in select patients using endoscopic approaches. Despite rigorous surveillance, we have identified 3 patients with renal parenchymal recurrences and/or metastatic disease without progression of renal pelvis disease. METHODS: Three patients with renal parenchymal and/or metastatic UC were identified through routine clinical care. Data on these 3 patients were obtained from medical records to identify possible explanations for this recurrence pattern. RESULTS: Three men (mean age, 68 years) were initially managed endoscopically (1 ureteroscopy and 2 percutaneous) for upper tract UC. Indications were solitary kidney in 2 patients and renal insufficiency in 1 patient. Two patients had low-grade disease and 1 patient had high-grade disease. Despite apparently successful management for 9 to 50 months, with complete tumor resection on initial and subsequent treatments, and at least 1 tumor-free period was documented in 2 of the 3 patients, parenchymal recurrence, metastases, or both were confirmed in 1 patient each. One patient underwent nephroureterectomy and the other 2 patients received adjuvant chemotherapy. CONCLUSIONS: Despite complete initial resection of upper tract disease and apparent successful surveillance, these 3 patients had renal parenchymal recurrence and/or metastatic disease without obvious progression of collecting system disease. Unless there is an imperative indication for organ preservation, nephroureterectomy should be considered as the primary option. Biopsy of subsequent lesions is recommended to evaluate for advancing grade, and periodic cross-sectional imaging should be used to evaluate for disease progression.