Around 1520 a new technnique of perineal lithotomy was introduced by the Italian surgeon Franciscus de Romanis of Cremona. The method was described and published by his student Mariano Santo di Barletta in his “Libellus aureus de lapide a vesica per incisionem extrahendo” in Venice in 1535 and was called the Marian operation.

This operation was based on the observation that stones could pass relatively easily through the short, dilatable female urethra. If the male urethra were made shorter and dilated, then stones could be more readily removed from the bladder. The Marian operation involved a larger number of instruments and was therefore called “apparatus major”. The Marian method was adopted within a short period by most European lithotomists.