Effect of circumcision on urinary tract infection (UTI) after successful antireflux surgery
Study published in BJU International, Volume 94, Issue 4, Pages 627-629 (Aug. 25, 2004). The authors concluded "that circumcision during antireflux surgery has no effect on the incidence of postoperative UTI."
The continuing practice of circumcision of newborn male infants, other than as a religious and cultural rite, remains something of an enigma. In a summary of the scientific data in 1971, the American Academy of Pediatrics Committee on the Fetus and Newborn issued an advisory note that 'there are no absolute medical indications for routine circumcision of the newborn.'. In part, because of this consensus, the circumcision rate has declined; however, currently the link to UTI during infancy has renewed the debate about neonatal circumcision. From proponents of neonatal circumcision there are warnings that the intact prepuce invites bacterial colonization, leading to ascending urethral infection which, in turn, can sometimes result in acute pyelonephritis and permanent renal damage. On the opposing side there is no proof that uncircumcised infants who sustain a UTI will have urological problems in the future. Furthermore, routine circumcision is not necessarily a simple procedure; possible dangers include penile amputation or death.
In 1985 Wiswell et al. reported the results of a study documenting the incidence of UTI during the first year of life in a large cohort of infants born at Brooke Army Medical Center over an 18-month period. They identified a significant association between circumcision status and risk of UTI in boys, and these findings prompted the American Academy of Pediatrics to reassess the issues involved in circumcision. In 1989, the Task Force on Circumcision issued a new statement, noting that the procedure had potential medical benefits and advantages, as well as disadvantages and risks. However, many questions about the relationship between circumcision and UTI remain unanswered. In particular, few studies have evaluated whether circumcision can provide prophylaxis in children with disorders such as VUR that predispose them to UTI . This disorder is found in 20-50% of children with UTI and at least a quarter of neonates and infants with VUR have had a UTI while receiving antimicrobial prophylaxis. In the series by Jodal there was (after ureteric reimplantation) a striking reduction in the rate of episodes of acute pyelonephritis in patients with VUR, but the overall rate of symptomatic UTI was not reduced by surgery. We evaluated whether circumcision at the time of antireflux surgery can reduce the incidence of UTI after successful ureteric reimplantation in patients with primary VUR.
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However, in the present results there was no significant difference in the recurrence rate of UTI after surgery between the uncircumcised and circumcised groups, regardless of age at operation; this suggests that the prepuce might not influence the development of UTI. In addition, there was no significant difference in the incidence of UTI before or after surgery between patients aged <1 or >1 year at operation. These findings suggest that age at surgery is not an important factor in the development of UTI.
Although some reports suggested that infection rates are initially higher in uncircumcised infants there is little to show that this leads to urological problems [2,4,9,10,13,14]. The reported rate of complications arising from circumcision is 0.2–0.6%[19], although if minor complications are also considered, the incidence may be as high as 35%. The mortality rate is 1 in 500 000 procedures [20]. Comparing the risks and benefits of circumcision, and in view of the lack of difference in UTI recurrence rates, we do not think that circumcision during antireflux surgery is beneficial.
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