Introduction and Hypothesis <p>Long-term outcomes following vaginal (V-USLS) versus laparoscopic (L-USLS) uterosacral ligament suspension have not been reported in the literature. Our objective was to compare long-term outcomes following V-USLS versus L-USLS following hysterectomy.</p> Methods <p>This was an ambispective cohort study at a single academic institution comparing patients who underwent a V-USLS following a vaginal hysterectomy or L-USLS following a laparoscopic hysterectomy from 2013 to 2018. The primary outcome was composite prolapse recurrence rate, combining subjective prolapse symptoms and objective failure, including prolapse beyond the hymen on pelvic organ prolapse quantification exam or retreatment. A power calculation determined 68 patients in each group would be required to detect a difference of 15% in recurrence rates. Statistical analysis was performed using Student’ <i>t</i>-test, Wilcoxon rank sum test, chi-square test, or Fishers exact test, and multivariable logistic regression where appropriate.</p> Results <p>Thirty-six patients in each group presented for a study visit. Preoperative POP-Q measurements were similar between groups. Surgical complication rates were low and similar between groups. Mean follow-up time was 6.8&#xa0;years, similar between groups. V-USLS had higher rates of recurrent prolapse beyond the hymen on POP-Q (33.2% vs 11.1%, <i>p</i> = 0.016), retreatment (25.0% vs 2.8%, <i>p</i> = 0.006), and composite failure (47.2% vs 22.2%, <i>p</i> = 0.019). Subjective prolapse symptoms were similar between groups. V-USLS was associated with a higher risk of prolapse recurrence (aOR 1.73 (95%CI 1.13–5.78). Anterior prolapse (Aa) was associated with higher recurrence risk, with aOR 2.04 (95%CI 1.15–3.62) per every 1 cm, up to 3 cm beyond the hymen.</p> Conclusions <p>On the basis of these results, L-USLS appears to have a decreased association with recurrence compared to V-USLS. Conclusions are limited by a small sample size.</p>