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The incidence of prostate cancer in Japan has risen dramatically in the past four decades. This increase, along with the advent of prostate-specific antigen (PSA) screening, has meant that an increasing number of patients are diagnosed at an early stage of the disease, when cure is possible. Currently, radical surgery and external-beam radiation are considered the standards of care for curative treatment of localized disease. Although many patients are helped by these treatment approaches, both are associated with potentially serious complications. Cryoablation is another option in the treatment of localized prostate cancer. The current technique utilizes real-time transrectal ultrasound (TRUS) for guidance and monitoring, multiple cryoprobes, a urethral warming device, multiple thermocouples, and two freeze-thaw cycles. Seven-year outcomes are now available for cryosurgical treatment of primary disease, and they indicate an efficacy similar to that of radical surgery and external-beam radiation in low-risk patients, and possibly superior efficacy in medium- and high-risk patients. Patients who experience a local recurrence following cryoablation can be successfully retreated. Bowel and bladder complications are minimal, and many patients regain the ability to have intercourse. Quality of life has been shown to return to baseline levels within 1 year following the procedure. Cryoablation has been successfully used as salvage therapy in patients with local recurrence, and preliminary evidence suggests that cryoablation may be effective in the treatment of focal disease, where less than the entire gland is targeted.

There have been significant improvements in the way prostate brachytherapy is currently performed, which have directly led to superior biochemical control rates and reduced side effect profiles. Transperineal ultrasound-guided approaches have replaced the open retropubic technique, and the 15-year results now available indicate excellent biochemical outcomes for patients with early-stage, low-risk cancer. In general, PSA relapse-free survival outcomes for favorable-risk disease have been reported to be approximately 90%, which is comparable to outcomes achieved with other interventions such as radical prostatectomy and high-dose conformal external-beam radiotherapy. Although urinary obstructive symptoms are commonly reported as acute effects observed immediately after therapy, these effects gradually resolve with time. Newer strategies in prostate brachytherapy are exploring techniques that will probably further enhance the accuracy of seed implantation with intraoperative planning methods. These approaches provide three-dimensional target and normal tissue reconstruction in the operating room during the procedure, which in turn can improve the accuracy of the seed placement and reduce the radiation dose levels delivered to the urethra and rectum. Reports of the use of these techniques indicate reduced urinary symptoms along with excellent biochemical control rates. Recently, methods have been developed to fuse the coordinates of biologic-based imaging abnormalities such as magnetic resonance spectroscopy on intra-operative ultrasound images and target higher doses to these regions. Real-time seed identification with reintegration of this information into the treatment plan in a dynamic mode will further enhance the precision of this procedure and likely lead to a further improvement in the quality of life among patients treated with prostate brachytherapy.

Applications of energy sources which were applied for endourology is discussed with special reference to efficient targeting gene delivery for the treatment of urological cancer. Gene therapy has attracted attention as a possible solution to many major diseases, such as cancer and cardiovascular disorders. The urogenital organs are excellent specific targets for the application and evaluation of gene therapy. Most gene therapy strategies have already been applied to urological cancers, with an acceptable safety profile but with limited clinical benefits and many hurdles to overcome. The efficient and safe delivery of therapeutic genes in vivo remains a major challenge to the realization of gene-based therapeutic strategies. Local injection of therapeutic gene (in situ gene therapy) is currently practical way with maximum efficacy and safety. Shock waves and ultrasound, therapeutic energies which were developed for endourology, have the potential to enhance the transfection efficiencies in a variety targeted tissues and cell types. Targeting energy-assisted local gene delivery into urologic organs using endourological techniques can be possible and will be one of the most effective modalities in the future endourooncology.