Although nephroureterectomy remains the gold-standard therapy for upper tract recurrence of transitional cell carcinoma after cystectomy and urinary diversion, conservative endoscopic techniques are increasingly being utilized for surveillance and management of recurrent low-grade upper tract lesions. A retrograde or antegrade approach is technically feasible and can be an effective alternative in patients with significant medical comorbidities, chronic renal insufficiency, bilateral disease, or solitary renal units. Recent series have expanded the utility of these procedures to include solitary, low-grade, and completely resectable tumors in patients with normal contralateral kidneys who are willing to accept lifelong surveillance for recurrence. With increasing experience and improvements in endoscopic equipment, the endourologic management of upper tract recurrence after cystectomy and lower urinary tract reconstruction is an appealing option in select patients. The difficulties with urinary tract access, preservation of renal function, and oncologic efficacy must all be taken into consideration in these complex patients. The aims of this report are to review the outcomes of contemporary series of upper tract recurrence of transitional cell carcinoma managed endoscopically, and to discuss the application of endourologic techniques in patients who have undergone cystectomy and lower urinary tract reconstruction.