PURPOSE OF REVIEW: This article reviews the current literature regarding surgical repair of vaginal apical prolapse and discusses the risks and benefits of various surgical approaches. RECENT FINDINGS: Vaginal uterosacral ligament suspension has similar anatomic and subjective outcomes to sacrospinous ligament fixation at 1 year. Native tissue vaginal repairs offer decreased morbidity compared with mesh-augmented sacrocolpopexy; however, sacrocolpopexy has greater anatomic success. Minimally invasive sacrocolpopexy appears to be equivalent to open abdominal sacrocolpopexy. Native tissue repairs and transvaginal mesh kits support the vaginal apex with similar results; however, long-term follow-up is needed. Robotic and laparoscopic sacrocolpopexy are equally effective in restoring the vaginal apex. SUMMARY: Surgical restoration of the vaginal apex can be accomplished via a variety of approaches and techniques. When deciding on the proper surgical intervention, the surgeon must carefully calculate the risks and benefits of each procedure while incorporating the patient's individual medical and surgical risk factors. Lastly, a discussion regarding the patient's overall goals of care is paramount to the decision-making process.