[kellyhound]

This is a 73 year old Chinese with PI (Penial incarceration). Physical examination demonstrated a swollen penis at the distal end of the metallic ring, no skin necrosis or numbness was reported, nor stinky odor was smelt. This copper hoop was 40 mm in the external diameter, with a 10 mm width and a 2 mm thickness.

A close physical examination found that the metallic hoop could be rotated slightly at the incarceration location. However, it could not be removed directly whatsoever. The patient's vital sign was stable.

The patient reported multiple comorbidities, including diabetes, high blood pressure (up to 190/110 mmHg), and coronary heart disease with four stents implanted. The patient took aspirin and clopidogrel routinely for secondary prevention purposes.

The patient reported that he "accidentally" put the copper hoop in his penis three months ago, and it was challenging to be taken off. As there was no acute pain, bleeding, or any other uncomfortable symptoms at that moment, he decided to do the self-observation rather than visit the emergency department.

During his observation period, he found that his penis gradually became swollen, and thereafter the urination gradually became arduous.

After three-months-long consideration, he decided to visit the outpatient department of our medical center on his own.

Aspirin and clopidogrel had been ceased seven days before the operation. Both the cardiology department and anesthesia department regarded the risk to anesthesia as acceptable for surgery. Firefighters stated that they had no experience in handling such cases.

Dentists suggested that the fixed dental drill might be an alternative, as they had previously tested its efficiency and feasibility on a stainless-steel nut. It could cut a 1 mm deep gap on the nut within 25 s, let alone the softer copper hoop in this case.

However, since the head of the dental drill was easily destructed, this plan was eventually abandoned.

Considering the familiarity with available equipment in the operating room, we also invited several scrubbing nurses for surgical instrument preparation. The fretsaw, which had been commonly used in the field of orthopedics and neurosurgery, was recommended.

They wrapped the distal penis with a bandage preoperatively to alleviate regional edema and placed a thin catheter between the penis and the hoop as a retraction.

The catheter was pulled out intraoperatively, and then a condom was cautiously placed. Nevertheless, because of the edema of the prepuce, we failed to take the hoop off by hand, even with lubrication.

Therefore, penile aspiration was performed to reduce the edema. Meanwhile, we exploited a pincher to fix the hoop, an intestinal spatula to protect the underlying skin, as well as sterile water for cooling secondary heat damage.

The foreign object was finally removed after 100 min of fretsaw cutting. There was scarcely any bleeding during the surgery. A urinary catheter was indwelled in case of temporary dysuria.

The catheter was withdrawn and the patient was discharged in good condition two days after surgery.

There were no complications like dysuria, erectile dysfunction, urinary irritation, or urethral fistula through telephone follow-up on the exact time of one month and one year after surgery.