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Objective: To examine the safety and efficacy of microwave tissue coagulation (MTC) for prostate cancer and assess its use in lesion‐targeted focal therapy in a non‐clinical study and a clinical phase II trial. Methods: In the non‐clinical study using Microtaze®‐AFM‐712 (Alfresa Pharma Corporation, Osaka, Japan) with an MTC needle, MTC was performed using a transperineal approach to targeted canine prostatic tissue under real‐time ultrasonography guidance. Using various MTC output and irradiation time combinations, the targeted and surrounding tissues (rectum, bladder and fat) were examined to confirm the extent of coagulative necrosis or potential cell death, and to compare intra‐operative ultrasonography and pathology findings. The exploratory clinical trial was conducted to examine the safety and efficacy of MTC. Five selected patients underwent transperineal MTC to clinically single lesion magnetic resonance imaging (MRI)‐visible lesions with Gleason score 3 + 4 or 4 + 4. Prostate‐specific antigen (PSA), MRI and Expanded Prostate Cancer Index Composite questionnaire findings were compared before and 6 months after surgery. Results: The region of coagulative necrosis was predictable by monitoring of ultrasonically visible vaporization; thus, by placing the MTC needle at a certain distance, we were able to perform a safe procedure without adverse events affecting the surrounding organs. Based on the non‐clinical study, which used various combinations of output and irradiation time, MTC with 30‐W output for 60‐s irradiation was selected for the prostate. Based on the predictable necrosis, the therapeutic plan (where to place the MTC needle to achieve complete ablation of the target and how many sessions) was strictly determined per patient. There were no serious adverse events in any patient and only temporary urinary symptoms related to MTC therapy were observed. Furthermore, post‐treatment satisfaction was very high. All preoperative MRI‐visible lesions disappeared, and PSA decreased by 55% 6 months after surgery. Conclusion: Microwave tissue coagulation may be an option for lesion‐targeted focal therapy for prostate cancer. [ABSTRACT FROM AUTHOR]