Pelvic organ prolapse (POP) affects approximately 40% of women in the United States during their lifetimes, presenting with symptoms such as vaginal pressure, urinary and defecatory dysfunctions, and sexual concerns [1]. Annually, around 200,000 urogynecologic procedures are performed in the USA to address these symptoms, with varying outcomes based on the chosen procedures and whether surgical or conservative routes were taken [2]. This chapter explores the vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach, particularly in the context of uterosacral ligament suspension (USLS) and uterine-sparing suspensions, discussing its feasibility, safety, and long-term outcomes. Both require the integration of the uterosacral ligament (USL) in the surgical technique.