To evaluate if ureteral compromise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS). A secondary objective is to evaluate if vaginal suture exposure is significantly different between these groups. This is a retrospective cohort study comparing women who underwent laparoscopic and vaginal USLS at two institutions from a single training program with procedures performed by 11 fellowship-trained urogynecologic surgeons from Jan 2008 to Jun 2013. A total of 208 patients underwent USLS - 148 laparoscopically and 60 vaginally. There were statistically significant differences between the groups in mean age (50.4 vs 55.3 yrs, p = 0.008), parity (2.44 vs 2.77, p = 0.040), and prior hysterectomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively, p = 0.042). There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.% vs 10.0%, respectively; p < 0.001). If only ureteral compromises requiring stent placement were counted, the higher rate of ureteral compromise in the vaginal group persisted (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; p = 0.023). The type of suture used for the suspension was significantly different between the laparoscopic and vaginal groups. Permanent suture was used more frequently in the laparoscopic group (90.5% vs 66.7%, p < 0.001). Clinically significant suture exposure, requiring removal in either the office or the operating room, was significantly higher in the vaginal compared to the laparoscopic group (10.0% vs 1.4%, p = 0.008). Permanent suture was used in 100% of laparoscopic cases and 83.3% of vaginal cases that resulted in suture exposure. There was a lower median estimated blood loss in the laparoscopic group (137.5 mL vs 200.0 mL, respectively; p = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; p = 0.025). There were no other significant differences in post-operative complications. We found a lower rate of ureteral compromise and a lower rate of clinically significant vaginal suture exposure in the laparoscopic approach to USLS compared to the traditional vaginal approach.