Objective To compare the perioperative safety and short-term efficacy of mesh-free laparoscopic high uterosacral suspension (LHUS) and conventional laparoscopic sacrocolpopexy (LSC) in the treatment of moderate to severe anterior and middle pelvic organ prolapse (POP). Methods A retrospective analysis was performed on 96 patients with moderate to severe anterior and middle POP admitted in Zhengzhou Central Hospital from January 2020 to December 2024. Patients were divided into LHUS group (n＝ 52) and the LSC group (n＝44) according to the surgical procedure. Moreover, perioperative indicators and 12-month postoperative outcomes were compared between the two groups. Results The LHUS group showed significantly shorter operation time, less intraoperative blood loss, shorter postoperative indwelling catheter duration and shorter hospital stay than those in the LSC group (all P＜ 0.05). There were no significant differences between the two groups in the 12-month postoperative objective cure rate (86.54% vs. 90.91%), point C values and subjective satisfaction (all P＞0.05). In the LSC group, there was 1 case of mesh exposure (2.27%). In the LHUS group, there were 3 cases (5.77%) of ureteral suturing adjacent to the mesh during the operation. After treatment, all patients had a good prognosis. Conclusion LHUS yields equivalent short-term efficacy to LSC for moderate to severe anterior and middle POP, and presents the advantages of minimal trauma, rapid recovery and absence of mesh-related complications. However, enhanced identification and protection procedures for ureters are required during surgery.