Objectives/Hypothesis: The definition of large-volume pathologic N1 metastases has been changed in the 2017 version 2 of the National Comprehensive Cancer Network guidelines, leading to a controversy over the optimal surgical approach selection for patients with biopsy-proven papillary thyroid carcinoma (PTC). The aim of this study was to investigate the therapeutic efficacy of total thyroidectomy (TT) and thyroid lobectomy (TL) for these patients. Study Design: Retrospective population-based database analysis. Methods: A total of 906 consecutive PTC patients with pathologic N1 metastases (>5 involved nodes with metastases ≤5 mm in the largest dimension) were retrieved from the Surveillance, Epidemiology, and End Results database, and divided into two groups (≤2 mm, >2–5 mm) based on the size of the extent of disease. Overall survival (OS) was then compared between patients treated with TT and TL, followed by Cox proportional hazards regression analysis to explore multiple prognostic factors. Results: OS favored TT compared with TL in patients with more than five involved nodes and metastases >2 to 5 mm in the largest dimension (P <.05). Cox analysis showed that the TL was not an independent factor associated with poorer OS than TT in these patients (P >.05). Conclusions: TT showed better survival than TL for patients with more than five involved nodes and metastases >2 to 5 mm in the largest dimension. For patients with more than five involved nodes and metastases ≤2 mm in the largest dimension, either TT or TL can be recommended because there was no difference in survival. Level of Evidence: NA Laryngoscope, 2019. © 2019 The American Laryngological, Rhinological and Otological Society, Inc.