Focal high-intensity focused ultrasound (HIFU) is a promising treatment for prostate cancer (PCa), offering excellent safety, preservation of urinary and sexual function, effective cancer control, and high patient satisfaction. It is applicable for both primary and radiorecurrent cases, with ideal candidates being those with intermediate-risk, unilateral clinically significant PCa (CSPCa). The tumor’s location is crucial in selecting focal therapy. HIFU targets the posterior prostate region, where CSPCa is often located, and where the probe can be positioned closer for precise treatment. Postoperatively, contrast-enhanced ultrasonography (CEUS) is useful for confirming successful ablation, and follow-up using prostate-specific antigen (PSA), MRI, and prostate biopsy is essential, since PSA and MRI have limited sensitivity in detecting recurrence after HIFU. Medium-term outcomes show excellent oncologic control and preservation of urogenital function, with most postoperative complications being mild. Minimal treatment decision regret is reported among patients. Future enhancements of focal HIFU, including new imaging technologies like prostate-specific membrane antigen—positron emission tomography, artificial intelligence-powered diagnostics, and genetic testing, could further improve patient selection and outcomes.