Study Objective: This study aims to evaluate and compare the anatomical and functional outcomes of two distinct apical suspension techniques performed during vaginal hysterectomy (VH) plus traditional Sacrospinous Ligament Fixation (SSF) and Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES)—assisted High Uterosacral Ligament Plication (USLP). Design: Retrospective cohort study (Canadian Task Force classification II-2). Setting: Department of Obstetrics and Gynecology, High-Volume University Hospital. Patients: A total of 45 women diagnosed with POP-Q Stage II to IV uterine prolapse who underwent surgery between January 2023 and January 2025. Interventions: Patients were stratified into two surgical cohorts: Group 1 (n = 25) underwent traditional VH plus SSF (VH + SSF), and Group 2 (n = 20) underwent VH plus vNOTES-assisted High USLP (VH + vNOTES-assisted High USLP). Measurements and Main Results: Primary outcomes focused on anatomical success (defined as POP-Q point C ≤ −5 cm). Secondary outcomes included operative time, complications (Clavien–Dindo classification), Total Vaginal Length, and de novo dyspareunia. While anatomical success rates were comparable between the groups (92% for SSF vs 95% for vNOTES, p =. 65), the vNOTES approach was associated with significantly superior functional outcomes. Group 2 achieved significantly greater postoperative Total Vaginal Length (8.5 ± 0.8 cm vs 7.8 ± 0.9 cm, p =. 04) and a lower incidence of de novo dyspareunia (4.8% vs 14.3%, p =. 03). Mean operative time was significantly longer in the vNOTES group (115 ± 22 minutes vs 90 ± 15 minutes, p =. 01). Conclusion: Both techniques provide effective apical support for advanced prolapse. vNOTES-assisted High USLP appears to offer potential advantages in preserving vaginal length and reducing de novo dyspareunia compared to SSF, though these findings must be interpreted cautiously due to the small sample size and retrospective design. The enhanced visualization offered by vNOTES mitigates the risks associated with traditional high USLP.