Background: We aimed to investigate the outcomes of anterior and posterior approaches in patients who underwent sacrospinous ligament fixation for apical prolapse. Methods: The study included hysterectomized women with grade \ge2 apical prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system, who presented to our center between 2019 and 2022. Out of the 48 patients included in the study, 24 underwent posterior bilateral sacrospinous ligament fixation (PB-SSLF), while the other 24 underwent anterior bilateral sacrospinous ligament fixation (AB-SSLF). Postoperative anatomical recurrence of anterior vaginal wall prolapse, according to the POP-Q system, was defined as follows: cystocele \ge stage II (Aa or Ba \ge–1 cm), recurrent apical prolapse \ge stage II (C \ge–1 cm), and posterior vaginal wall prolapse \ge stage II (Ap or Bp \ge–1 cm). Postoperative follow-up visits were scheduled routinely at 1, 3, 6, and 12 months after the operation, and then annually. Complications were recorded according to the Clavien-Dindo classification. Rates in the groups were compared using the Chi-square test. Independent two-group comparisons of numerical variables were performed using the Student t-test when the normal distribution assumption was met and the Mann-Whitney U test when the assumption was not met. The significance level (alpha) was set at p 0.05. Results: No significant difference was observed in terms of postoperative anterior recurrence between the groups that underwent bilateral anterior and posterior SSLF (16.7% each). Regarding the operation durations, the group that underwent AB-SSLF had longer operation times compared to the group that underwent PB-SSLF (80 minutes and 42.5 minutes, respectively). A higher incidence of postoperative urinary dysfunction was observed in patients who underwent anterior bilateral sacrospinous ligament fixation (p = 0.012). No grade 3b or higher complications were observed according to the Clavien-Dindo classification. Conclusions: AB-SSLF is an effective method in the surgical treatment of apical and anterior pelvic prolapse. However, the anterior compartment failure rate is still a limitation. Further research is required to investigate its long-term efficacy.