Background and Purpose: Upper tract transitional-cell carcinoma (utTCC) is uncommon. Standard evaluation includes imaging, cytology, and cystoscopy and gold standard treatment is nephroureterectomy (NU) with solid oncologic outcomes and elevated morbidity. In this study, we report on the value of including routine ureteroscopy (URS) for evaluating suspected utTCC in shifting the treatment toward less morbid options and increasing preoperative diagnostic accuracy. Patients and Methods: Records of patients presenting between 2002 and 2013 with suspected utTCC were reviewed. Since 2010, URS has been included routinely in the evaluation protocol. Demographic, clinical, and pathologic characteristics were recorded and compared between earlier experience (group 1) and with routine URS (group 2). In addition, the number needed to treat (NNT) was calculated with respect to shifting the procedure choice from NU to other options as well as in reducing the rates of misdiagnoses. Results: A total of 118 patients were included: 63 in group 1 and 55 in group 2. The pathology-confirmed TCC rates were comparable between the two groups (78 vs 85%). The rates of NU decreased with routine URS use from 89% to 69% (P=0.011, NNT=5.05) whereby patients were treated endoscopically or with distal ureterectomy. Misdiagnoses decreased from 15.5% to 2.1% with routine URS (P=0.021, NNT=7.44). Sepsis occurred in two patients after URS. Conclusions: In this initial study, routine URS evaluation for suspected utTCC appears to enable an increased use of other treatment choices rather then NU, with an estimated five URS avoiding one NU. Moreover, routine URS reduced the rates of misdiagnosis of TCC. Complications associated with URS may add an additional morbidity burden, however.