Background The use of mesh is controversial in the treatment of female pelvic organ prolapse. Objectives To systematically review the outcomes of sacrocolpopexy compared with transvaginal mesh surgery and to provide evidence-based suggestions. Search strategy The MEDLINE, EMBASE, Cochrane Library and clinicaltrials.gov databases were searched on 21 November 2018. Selection criteria Randomised controlled trials and prospective and retrospective cohort studies were included. Data collection and analysis Data were extracted by one reviewer and examined by a second reviewer for accuracy. Odds ratios and 95% CI were calculated using random-effects models. Main results Twenty comparative studies were included. The metaanalysis was performed with subgroups. The summary odds ratios of the randomised controlled group were 1.84 (95% CI 0.79-4.29, I 2 = 75%) for anatomical success, 1.41 (95% CI 0.47-4.24, I 2 = 38%) for subjective success, 0.42 (95% CI 0.18-0.98, I 2 = 0%) for mesh complications, 0.61 (95% CI 0.20-1.91, I 2 = 0%) for prolapse reoperation and 0.44 (95% CI 0.23-0.88, I 2 = 0%) for de novo dyspareunia. The mean differences were 0.77 (95% CI 0.31-1.23, I 2 = 66%) for total vaginal length and À1.28 (95% CI À2.00 to À0.55, I 2 = 66%) for point C after surgery. Conclusions Very-low-quality evidence indicated that the anatomical and subjective success rates of sacrocolpopexy were similar to those of transvaginal mesh surgery; sacrocolpopexy might be more beneficial than transvaginal mesh surgery in terms of mesh-related complication rates, prolapse recurrence and de novo dyspareunia. However, additional high-quality randomised trials with long-term follow-up durations are needed.