INTRODUCTION: Papillary thyroid carcinoma is the most common type of thyroid cancer worldwide. While total thyroidectomy is widely considered the standard surgical approach for papillary thyroid carcinomas, the role of central lymphadenectomy in early stage poor-risk papillary thyroid tumors is still a matter of debate. This study was designed to assess surgical complications and local disease control rates in patients affected by poor-risk early stage papillary thyroid carcinomas. METHODS: We retrospectively analyze three groups of patients affected by poor-risk early stage papillary thyroid carcinomas treated with three alternative surgical strategies: I) routine total thyroidectomy; II) total thyroidectomy and routine central lymphadenectomy; III) total thyroidectomy and central lymphadenectomy upon positive intraoperative histological evaluation of lymph node involvement. RESULTS: Data from patients treated with routine total thyroidectomy showed 32% of persistence of disease in the central compartment with concurrent positivity in laterocervical compartment in 25% of these cases. By contrast, patients receiving total thyroidectomy and routine central lymphadenectomy showed the involvement of central compartment in 40% of cases, while the remaining 60% of patients were free from lymph node metastases. Finally, patients undergoing total thyroidectomy and central lymphadenectomy upon positive intraoperative lymph node biopsy exhibited lack of persistence of lymph node involvement in central compartment after surgery. Of note, postsurgical complications were lower in patients undergoing conservative surgical approaches. CONCLUSIONS: These data suggest that central lymphadenectomy, performed only in case of positive intraoperative lymph node biopsy, ensures reduced incidence of postoperative complications and optimal loco-regional disease control.