The authors recommend circumcision only for boys at high risk of urinary tract infection, but this view is not universally held, commentators suggest.

A reduced rate of urinary tract infection is the most frequently cited benefit of circumcision, Dr. Jonathan Craig and his team at the Children's Hospital at Westmead in Sydney, Australia, note in their report, published in the Archives of Disease in Childhood.

To further investigate, they searched databases to identify studies published between 1987 and 2001 that reported on circumcision and urinary tract outcomes. Their review included 12 articles documenting outcomes for approximately 403,000 children and 1953 episodes of urinary tract infection. Maximum follow-up was 3 years.

Circumcision was associated with a significantly reduced risk of urinary tract infection, a "substantial reduction," the authors note. They calculate that "the number-needed-to-treat to prevent one urinary tract infection is 111" in normal boys. Also, they add, circumcision is associated with a 2 percent to 10 percent complication rate.

Craig and colleagues estimate that the risk of urinary tract infection is 1 percent in normal boys, 10 percent in boys with a history of urinary tract infection, and 30 percent in boys with high-grade reflux of the bladder and ureter.

They recommend that circumcision be considered for boys with a history of urinary tract infection or high-grade bladder and ureter reflux, because the "benefit outweighs the risk of complications in these cases."

Reflecting a "North American view," Dr. Edgar J. Schoen, from Kaiser Permanente Medical Center in Oakland, California, suggests in a related commentary that the researchers' interpretation of their findings is flawed.

For example, he notes, circumcision is ideally performed in newborns, where the complication rate is approximately 0.2 percent to 0.6 percent. He also advocates its use because of other health benefits, such as prevention of penile cancer, some sexually transmitted diseases and HIV.

But in a second commentary giving a "European view," Dr. Padraig S. J. Malone, from Southampton University Hospitals NHS Trust in the UK, remarks that "it is doubtful that a cost-benefit analysis could ever justify routine circumcision" to prevent urinary tract infections. He does, however, recommend further studies to examine the benefit of routine circumcision in preventing kidney scarring.

SOURCE: Archives of Disease in Childhood, August 2005.