Introduction and Hypothesis <p>To compare anatomical outcomes, surgical success, and perioperative morbidity between abdominal sacrohysteropexy (mesh-based) and abdominal high uterosacral ligament suspension in premenopausal women undergoing uterine-preserving surgery for symptomatic uterovaginal prolapse.</p> Methods <p>In this randomized controlled trial, 60 premenopausal women with stage II or higher uterovaginal prolapse were randomly assigned (1:1) to undergo either open abdominal sacrohysteropexy or abdominal high uterosacral ligament suspension. The primary outcome was apical surgical success at 12 months, defined as point C ≤−2 on Pelvic Organ Prolapse Quantification examination and an absence of vaginal bulging symptoms. Secondary outcomes included anterior and posterior compartment measurements (Ba, Bp), operative time, hospital stay, complications, and new-onset urinary incontinence.</p> Results <p>Sixty patients (30 per group) completed the 12-month follow-up. Surgical success was achieved in 83.3% of patients in the sacrohysteropexy group and 90% in the uterosacral ligament suspension group (<i>p</i> = 0.47). Mean postoperative point C was significantly lower in the sacrohysteropexy group (<i>p</i> = 0.001). Both groups demonstrated significant improvement in Ba and Bp values. Operative time, hospital stay, and hemoglobin drop were significantly greater in the sacrohysteropexy group. Two cases of stage IV recurrence occurred in the sacrohysteropexy group. No mesh extrusion was observed.</p> Conclusions <p>Both open abdominal sacrohysteropexy and abdominal high uterosacral ligament suspension provide effective apical support in premenopausal women seeking uterine preservation. Although overall success rates were comparable, uterosacral ligament suspension was associated with shorter operative time and reduced perioperative morbidity. Surgical choice should be individualized, and larger studies with longer follow-up are warranted.</p>