The evolution of UUI treatments

By BECKY GILLETTE

Until recently, patients with urge urinary incontinence (UUI) had limited options, such as pelvic floor exercises, medications (which don’t help everyone), surgical implants requiring general anesthesia for a procedure in the operating room, and Botox injections, which risk urinary retention and require numerous repeated procedures.

Incontinence can drastically interfere with one’s quality of life, making it difficult for people to do normal activities like attending church, watching sporting events or taking a long car ride without diapers or access to a bathroom every 30 minutes.

Fortunately for patients, a new solution for UUI is now available that may be a game changer for many. This past December, W.V. "Rusty" Shappley, III, MD, became the first urologist in Tennessee to implant a Medtronic Altaviva™ device, which uses neuromodulation technology to stimulate the tibial nerve, helping to relieve incontinence symptoms.

Altaviva is implanted near the ankle in a reproducible, minimally-invasive procedure with a one-centimeter incision. The devices can tremendously improve lives.

“One patient told me that he was able to drive to Nashville without having to stop six or seven times for the first time in many years,” Shappley said. “This is an excellent tool to add to the urologists’ toolbelt. The surgery is a simple experience that does not require general anesthesia, and recovery time is minimal. Implantable tibial neuromodulation is a newer technology, and this is the latest device Medtronic has put out that is FDA approved for UUI.”

Shappley, who practices with his father, W. Vance Shappley, Jr., MD, said when his father first implanted devices for UUI, batteries had to be changed every 16 months. The Altaviva battery will last about 15 years and only needs to be recharged once or twice a year.

“Almost 30 years ago, Medtronic introduced InterStim™, a sacral neuromodulation device to treat UUI,” the younger Shappley said. “While sacral neuromodulation technology still works extremely well, it isn’t always as convenient and requires a 20- to 30-minute operation under general anesthesia. Some patients are at an age where the risks to cognition from general surgery are significant. I had a patient like this who opted for the Altaviva and he is delighted with the results. We didn’t have this technology until this past year. When I tell patients the solution might be relatively easy, a light comes on. I love the opportunity to give someone who is taking medications that haven’t worked for a long time and do something that can provide excellent outcomes for a better quality of life. It is very rewarding. I absolutely love that part of my practice. My dad and I enjoy what we do for a living, and like to provide medical advances such as this.”

A frustrating aspect of being a urologist is that, for a variety of different reasons, people are often uncomfortable discussing the urinary tract and the male reproductive system. Patients might even have an appointment but find themselves embarrassed to talk about it in an office setting with a stranger.

“When it comes to leakage of urine, it is embarrassing to a lot of people,” Shappley said. “Incontinence is a very significant quality-of-life issue, affecting them every day. Incontinence is an extraordinarily common and severely underreported problem—half of people in America may have an issue with it at some point in their lives. Men can be reluctant to see a doctor about it. It might be a family member who notices odor, or the number of diapers he uses. You can ask him if he has any problems with incontinence and he will say, ‘No.’ But then a family member will pipe up and say, ‘What about the four diapers you are using per day?’”

Often patients have comorbidities including life-threatening issues like diabetes or untreated hypertension. When seeing a primary care doctor, the patient is likely to focus on the most serious, life-threatening issues while dodging quality-of-life issues like incontinence. Primary care doctors have limited time and may not inquire about incontinence if it hasn’t been brought up.

Vance Shappley has often had a female patient tell him that her husband needs to come in because he is leaking urine.

“It might take a little coercion to get him in,” Shappley said. “Many times, patients might opt for medications instead of something that might be a greater benefit because of work and family responsibilities.”

Urology is a rapidly changing specialty. When the father and son first started practicing together, the son benefitted from his dad’s decades of experience, and the father learned from the latest his son had learned at medical school. As children, the son and his brother often accompanied their dad to the hospital for rounds and emergencies, spending many hours haunting the nurses’ stations and doctors’ lounge.

Rusty Shappley grew up knowing he wanted to be a surgeon but initially gravitated to neurosurgery. At medical school, after spending time with the different specialties, he decided urology was the best fit.

“I found it very engaging,” he said. “I listened to my gut and did what I wanted to do. I also knew I wanted to work at a destination close to family, so I was happy to return to Memphis from Boston. Having someone with decades of experience to consult with has been incredibly valuable throughout my career. It’s been fun working together. Since I joined 18 years ago, we merged with The Urology Group, successfully recruited, and are now the largest urology practice in the area.”

Some people believe incontinence is just a part of getting older.

“But just because a medical problem is very common doesn’t mean you just have to endure it,” said Vance Shappley, who will soon also be certified to implant Altaviva. “Men are coming around to deciding hormonal replacement is okay. With UUI, you see people avoiding activities that they love. People are delighted to learn there is a solution that can give them back freedom from needing to be near a bathroom every 30 minutes.”

Patients are evaluated and managed with the options of medicinal therapy before moving to surgical intervention, as recommended by the American Urological Association guidelines, which the Shappleys rigorously follow for a variety of conditions.

Vance Shappley, who completed his medical education at University of Tennessee Health Science Center, has 60 years of experience. Rusty Shappley, who graduated from Duke University and Columbia University College of Physicians & Surgeons in New York, is married to Rebekah Shappley, MD, a pediatrician who is an assistant dean at UTHSC. The couple have three boys ages 8, 10 and 12.

Vance’s younger son, Robbie Shappley, JD, MBA, works as a hospital administrator for University of Southern California.

Shappley credits his dad with pioneering The Urology Group’s interest in the latest medical innovations.

“One thing my father has always done is stay abreast of trends,” Shappley said. “He was the first urologist in the area to adopt electronic medical records, the first to hire Physician Assistants, and the first in the area to implant the InterStim device decades ago. He is always interested in urology improvements. As we encounter newer technologies like the Altaviva device, we continue to explore them together.”