We evaluated the recurrence after radical and partial nephrectomy in patients with RENAL nephrometry score [RENAL] ≥ 10. A total of 474 patients (radical nephrectomy [RN, n = 236] & partial nephrectomy [PN, n = 238]) in a single tertiary referral institution from December 2003 to December 2019 were assessed. Functional outcomes, defined as estimated glomerular filtration rate changes, relapse pattern, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were evaluated using propensity score-matched analysis. The predictors of recurrence and survival were assessed by Cox-regression analysis. 44 patients in the RN group and 88 in the PN group were included without significant differences in preoperative clinical factors after matching. The PN patients achieved significantly higher renal function preservation rates (p < 0.001). There were five recurrences in RN and six in PN. The PN patients revealed 5-year RFS rate (86.8%), 5-year CSS rate (98.5%), and 5-year OS rate (98.5%) comparable to the RN patients (RFS: 88.7% [p = 0.780], CSS: 96.7% [p = 0.375], and OS: 94.3% [p = 0.248]). Patients with a body mass index (BMI) ≥ 23 had lower 5-year RFS rates (85.5%) and OS rates (95.6%) than those with BMI < 23 (RFS: 90.0% [p = 0.195], OS: 100% [p = 0.117]) without significance. The significant predictor of recurrence was the pathologic T stage (hazard ratio [HR] 3.99, 95% confidence [CI] 1.10–14.50, p = 0.036). The significant predictor of death was the R domain of the RENAL (HR 3.80, 95% CI 1.03–14.11, p = 0.046). PN, if technically feasible, could be considered to preserve renal function in patients with RENAL ≥ 10. Nonetheless, PN needs to be implemented with caution in some patients due to the higher potentiality for recurrence and poor survival.