Objectives To evaluate longitudinal changes in urinary function and quality of life, and the oncological outcomes of patients treated with urethra‐sparing high‐intensity focused ultrasound for localized prostate cancer. Methods Patients with negative findings in the urethra and the anterior urethral zone using transrectal ultrasound‐guided targeted biopsies, and magnetic resonance imaging, received urethra‐sparing or whole‐gland high‐intensity focused ultrasound as the primary therapy for localized prostate cancer without transurethral resection of the prostate. Longitudinal changes in urinary function and quality of life, and the oncological outcomes of the patients were analyzed retrospectively. Results The median follow‐up times for urethra‐sparing and whole‐gland high‐intensity focused ultrasound were 36 and 30 months, respectively. Comparing the patients treated with urethra‐sparing high‐intensity focused ultrasound (n = 45) with those treated with whole‐gland high‐intensity focused ultrasound (n = 65), there were significant differences in the International Prostate Symptom Score (P = 0.014) at 3 months, International Prostate Symptom Score quality of life (P = 0.033) at 3 months, maximum urinary flow rate (mL/s; at 3 months, P = 0.010; at 6 months, P = 0.038) and residual urine volume (mL; at 3 months, P < 0.0001; at 6 months, P = 0.016; at 12 months, P = 0.028). For quality of life, there were significant differences in Functional Assessment of Cancer Therapy – General (at 3 months, P = 0.022) and Functional Assessment of Cancer Therapy – Prostate (at 3 months, P = 0.028; at 6 months, P = 0.034). There were no significant differences in oncological outcomes regarding negative biopsy rates on follow up (91% vs 92%; P = 0.8) or biochemical disease‐free survival rates (86.7% vs 89.2%; P = 0.7). Conclusions Urethra‐sparing high‐intensity focused ultrasound might prevent prolonged bladder outlet obstruction, and could be a treatment option for localized prostate cancer.