Pelvic organ prolapse is a common problem in women that increases with age and adversely affects quality of life and sexual function. If conservative treatments fail, surgery becomes the main option for symptom abatement. For uterovaginal prolapse, treatment with or without hysterectomy can be offered, and operations must include a specific apical support procedure to be effective. Operations for apical prolapse include transvaginal, open, and laparoscopic or robotic options; few clinical trials have compared the effectiveness and risk of these various surgeries. Grafts can be used selectively for apical suspensions and may improve cure rates but also increase risk of some complications. Slings should be added selectively to reduce postoperative stress incontinence. For women interested in future sexual activity who require apical prolapse surgery, we suggest using transvaginal apical repairs for older patients, those with primary or less severe prolapse, and those at increased surgical risk. We recommend sacral colpopexy with polypropylene mesh (preferably by minimally invasive route) in younger women, those with more severe prolapse or recurrences after vaginal surgery, and women with prolapsed, short vaginas. In older women with severe prolapse who are not interested in sexual activity, obliterative operations are very effective and have high satisfaction rates. An interactive consent process is mandatory, because many decisions—about route of surgery; use of hysterectomy, slings, and grafts; and vaginal capacity for sexual intercourse—require an informed patient's input. Selective referral to specialists in Female Pelvic medicine and Reconstructive Surgery can be considered for complex and recurrent cases.