Background <p>Implantation of irradiation stents demonstrates superiority over conventional metal stents in terms of stent patency and survival for patients with distal malignant biliary obstruction. Here, we aimed to explore the efficacy and advantages of irradiation stents compared with conventional metal stents in patients with unresectable malignant hilar biliary obstruction (MHBO).</p> Method <p>Unresectable MHBO patients treated with irradiation stents (IS group) were prospectively enrolled and followed up, and patients treated with conventional stents (CS group) were retrospectively enrolled by propensity score matching. The end of the follow-up period was recorded as either the date of death or 2&#xa0;years after stent implantation. The primary endpoint was stent restenosis, while secondary endpoints included technical success, jaundice remission, complications, and survival.</p> Results <p>A total of 44 patients were enrolled in this retrospective study (22 in each group). Stents were successfully implanted in all patients. Relief of jaundice was comparable between groups (IS: 81.8% vs. CS:77.3%, <i>P</i> = 0.71). IS group demonstrated superior stent patency with significantly lower restenosis rates (4.55% vs. 22.73% at 180&#xa0;days, <i>P</i> = 0.041) and unreached median patency time versus 254&#xa0;days in CS group. Type of stent was the only independent protective factor for stent patency (SHR: 0.12, 95%CI: 0.016–0.928, <i>P</i> = 0.042), while no significant differences emerged in overall survival or complication rates between groups. But multivariate regression analysis suggested that subsequent chemotherapy might provide certain survival benefits.</p> Conclusion <p>Implantation of irradiation stents could prolong stent patency but not affect survival for patients with MHBO.</p>