by Glenn Collins

After nearly 19 months of controversy and intermittently turbulent public hearings, the New York City Landmarks Preservation Commission voted Tuesday to approve a luxury condominium tower that is the financial linchpin of a two-tower, $1.63 billion reconstruction proposal by St. Vincent’s Hospital Manhattan that would modernize its facilities in the Greenwich Village Historic District.

After months of objections by commissioners, the 9-to-1 vote — in the ninth public hearing on the project — endorsed a 203-foot-tall, 16-story residential building that would occupy the east side of Seventh Avenue, between West 11th and West 12th Streets, in the historic district.

Originally, the hospital, in conjunction with the Rudin Management Company, proposed a 266-foot-tall condominium, but after repeated objections from the commissioners over its size and architectural features, the tower was whittled to 233 feet last year and to 218 feet in June, and is now an additional 15 feet shorter.

The tally effectively gave the approval of the landmarks commission to the entire St. Vincent’s proposal, since the commissioners already voted, 8 to 3, in March to permit the hospital to build an $830 million, 286-foot-tall medical building, after St. Vincent’s had originally proposed a 329-foot tower. It subsequently suggested a 299-foot-tall redesign, but requests and criticism from the commissioners in December spurred a shrunken version.

The project still requires approval from the New York City Planning Commission and the City Council, and construction could not begin, under the most optimistic projections, until 2012.

“Without a doubt, this application has posed the most complex historic preservation issues in recent memory,” said Robert B. Tierney, the commission’s chairman. He added that the plan “now successfully meets the challenge of knitting together the old and the new.”

The developer William C. Rudin said that “the process was fair and balanced, and we’re happy we got approved.”

The hospital had said it needed some $300 million from the Rudin company to help pay for its own hospital tower. (Mr. Rudin said the exact payment had not yet been calculated.) Now, the plan has advanced over “a very significant hurdle,” said Henry J. Amoroso, president of St. Vincent Catholic Medial Centers, the entity that includes the hospital. “We’re very happy.”

Nevertheless, a coalition of New York historic preservation and community groups filed suit against the commission and the hospital in March, seeking to block the project.

And the lone dissenter on the commission, Margery H. Perlmutter, said, “I still think the Seventh Avenue building is too tall.”

Andrew Berman, executive director of the Greenwich Village Society for Historic Preservation, said after the vote that “it’s certainly not over,” since the proposal will segue to the planning commission and the City Council.

From the beginning, critics have assailed the mass and height of the proposed towers and their impact on the historic neighborhood, while the hospital’s supporters underscored the need to upgrade St. Vincent’s.

The commissioners had already voted to demolish the 44-year-old Edward and Theresa O’Toole Medical Services Building, a landmark, sawtooth-sided neighborhood monument the hospital owns on Seventh Avenue between 12th and 13th Streets, where the hospital would be built.

Last year the commission said the hospital could not tear down O’Toole, given its status in a landmark district, but the hospital reapplied and won approval under provisions that permit institutions to claim hardship as a reason to demolish old buildings if they can prove that the maintenance of structures they own interferes with their ability to carry out their charitable purpose.

Public testimony and the statements of some commissioners, like Roberta Brandes Gratz, claimed that O’Toole was “an iconic modern landmark,” as Ms. Gratz said. They argued demolishing it would set a bad precedent since the building is suitable to be used by the hospital.

The lawsuit by preservation and community groups, which is pending, claimed that the commission members failed to follow the hardship standard established by the United States Supreme Court during two previous preservation battles that saved Grand Central Terminal and that prevented St. Bartholomew’s Church from demolishing its community house to build a 59-story office tower so it could finance church programs.

Commissioners who had supported the hardship application have defended their votes, and the hospital has said that preservationist groups were seeking to prevent it from building “a modern medical facility to serve Manhattan’s West Side.”