Purpose <p>To evaluate the impact of pelvic radiation therapy on artificial urinary sphincter cuff outcomes and to determine the optimal timing of artificial urinary sphincter insertion after radiation therapy in patients with post-prostatectomy stress urinary incontinence.</p> Methods <p>This retrospective study included 283 patients who underwent artificial urinary sphincter placement between 2003 and 2023. Cuff revision and removal rates were analyzed using Kaplan–Meier survival analyses and competing risk models. Cox proportional hazard regression was used to identify the predictive factors. Restricted cubic spline analysis was used to determine the optimal timing of artificial urinary sphincter insertion after radiation therapy.</p> Results <p>Over a median of 2.8 years, 54 patients (20.3%) required cuff revision and 17 (7.4%) underwent cuff removal. Radiation therapy was not significantly associated with cuff revision but increased the risk of cuff removal more than threefold (hazard ratio: 3.30, 95% confidence interval: 1.05–10.40, <i>P</i> = 0.041). Patients with prior radiation therapy underwent significantly earlier and more frequent cuff removals than those without prior radiation therapy (<i>P</i> = 0.003) and had a significantly higher cumulative risk of cuff removal (<i>P</i> = 0.04). Additionally, exploratory restricted cubic spline analysis showed a trend suggesting that AUS insertions performed after 635 days (1.74 years) post-radiation therapy were associated with lower rates of cuff removal, though not statistically significant.</p> Conclusion <p>Previous radiation therapy significantly increased the risk of artificial urinary sphincter cuff removal but not revision. Exploratory analysis suggests that the timing of AUS insertion after RT may influence cuff removal rates, with a trend toward lower risk after 1.74 years post-RT. These findings warrant further prospective investigation.</p>