Albucasis Role in the Development of Perineal Cystolithotomy: A Historical systemic Review

Introduction

Descriptions of Perineal cystolithotomy can be found in ancient Indian, Chinese, Babylonian, and Greek medical texts. An Egyptian excavation revealed the oldest bladder stone, which dates to around 4800 BCE, in the grave of a 16-year-old boy. In 1901, the English archaeologist Edwin Smith reported the discovery of a bladder stone in a mummy from El Amrah, Egypt, estimated to be approximately 4,500–5,000 years old. This finding is significant because it represents one of the earliest known cases of urolithiasis (bladder stone disease) in human history.¹³ This remarkable find provides early evidence of urinary tract conditions affecting humans in ancient times. The Hippocratic Oath of  “Neither will I cut those who have the stone,” ^{1, 20}  without due emphasis on its subsequent qualification, “but will leave this procedure to those who are trained and experienced in performing it.”^{1, 20} Bladder and urethral stones, occurring in both children and adults, have long represented a significant urological problem in the Arab world. Their treatment was thoroughly described by early physicians such as Albucasis, Rhazes (AD 850–923), Hali Abbas, and Avicenna (AD 980–1037). But Albucasis (Al-Zahrawi), the renowned 10th-century Muslim surgeon, invented the perineal cystolithotomy, a surgical technique for removing bladder stones through an incision in the perineal region. Albucasis was born in Zahra, near to Cordova, around 936 AD.¹ His real name was Abul-Qasim Khalef ibn Abbas Al-Zahrawi.²At that time, there was a huge University in Cordova. He is widely recognized in Western historical text as Zahravius or Albucasis.³ He serving as the court physician to Caliph Al-Hakam II at the time recognized as the “Golden Age” of Arab Spain. After a long and distinguished medical career, he died in 1036 AD at the age of 77. ⁴ He was a devout and humble man who dedicated much of his time to serving the poor. To perform the operation, he always shaved the area first. ⁵ Venesection, tonsillectomy, wound debridement , Fistulectomy, Haemorrhoidectomy, Herniotomy Cupping, and cauterization constituted the major form of surgical practice at that time.⁶ There was approximately 50 hospitals in the Cordova.⁷ The name Al-Tasrif is associated with a monumental medical vade mecum, composed of thirty volumes covering various branches of medicine, including anatomy, pharmacology, and therapeutics. The thirtieth and final volume is the most renowned, as it deals exclusively with surgery and surgical instruments. This section, often referred to as “On Surgery and Instruments”, includes detailed descriptions of operative techniques and over 200 surgical tools, many of which were illustrated for the first time in medical history.⁸ Al-Tasrif was the first illustrated and systematic text on surgical subjects. While much of its content was adapted and modified earlier contributions particularly those of Paul of Aegina and other Greco-Roman physicians. Albucasis’s meticulous descriptions and structured guidance reflected a cautious, ethical, and thoughtful approach to surgical practice.⁹ In general, 28^th treaties of Al-tasrif strictly related to pharmacy. ¹⁵  The 28th treatise became widely recognized in Europe under the Latin name Liber Servitoris. It deals predominantly with pharmaceutical techniques for manufacturing tables, lozenges troches, syrups, etc,..¹⁶  The second section and 29th treatise is historical significance. It deals with the synonyms of drugs in several languages Arabic, Greek, Syriac, Latin, and Spanish organised in alphabetical order, along with substitutes of drugs and a discussion of weights and measures of drugs.Finally, the 30th treatise of the book, structured three sections (abwab) is on surgery and its application. The first section, comprising 56 chapters, provides a detailed account of various aspects of cauterization. It explains classical texts related to the cautery of fistulas at the inner corner of the eye, as well as cauterization of the stomach etc., The second section, consisting of 93 chapters, deals to incision, perforation, wound debridement and healing, bloodletting, and both wet and dry cupping. The third section focuses on fractures and dislocations of joints, including pelvic fractures, techniques of bone-setting, and the management of bruises and joint injuries.¹⁰ The total number of pages in this book is 1000 and consisting of 30 volumes.¹⁰ It contained more than 200 illustrations and descriptions of surgical instruments, most of which were created by Al-Zahrawi himself. ¹¹ He was the first medical writer to illustrate surgical tools. ¹² Abul Qasim Khalaf Ibn Abbas Al-Zahrawi (Albucasis) discussed the surgical extraction of bladder stones in the well-known Thirtieth Treatise of his medical encyclopedia, Al-Tasrif. Sushruta, an ancient Indian surgeon who lived around 600 BCE, is regarded as one of the earliest pioneers of surgery. He authored the Sushruta Samhita, a foundational text in Ayurvedic medicine. This comprehensive work describes over 300 surgical procedures and details the use of more than 120 surgical instruments. Notably, Sushruta provides a thorough account of perineal lithotomy a procedure to remove bladder stones through an incision in the perineum. ¹⁴  Albucasis (AD 936–1013) advised crushing stones that were large or irregular in shape. He introduced the used of michab, an instrument inserted via the urethra to drill and fragment the calculus, allowing the pieces to be washed out subsequently with urine.¹⁵ The aim of this study is to examine historical sources and surgical practices related to perineal cystolithotomy, with a focus on evaluating and highlighting the significant contributions of Albucasis (Abu al-Qasim al-Zahrawi). In particular, this study explores his innovations in surgical technique, instrumentation, and ethical practice, and how his work profoundly influenced the development and evolution of urological surgery. ¹⁵

List of abbreviations and acronyms.

Methodology

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews (PRISMA) standards.

Search Strategy

A systematic review literature search, between 1959 and 2010, was conducted using the following databases: PubMed, Elsevier, Embse and CCRUM Library. A dual-approach search strategy was adopted, using free-text terms alongside Medical Subject Headings (MeSH) was used to identify relevant studies e.g., “Albucasis “, “Al-Tasrif” , “Urolithiasis”,  “Perineal Cystolithotomy”, “michab“, “Rhazes“, “PRISMA”, “Jarahat”, “Al-Zahrawi Instruments”,  MH “Al-Zahrawi Surgical Procedure”, “Kidney Stone”, “Ancient Cystolithotomy”, “Historical background Albucasis”.

Study Selection

The search was conducted by two investigators, who seprately screened all titles and abstracts for eligibility in accordance with the inclusion and exclusion criteria. Studies were included in the review based on the following inclusion criteria: 1) Studies observed Perineal Cystolithotomy 2) Studies related to the historical Background of Albucasis 3) Review Article related to Al-Tasrif and 4) Studies published in English language in a peer-reviewed indexed journal. The exclusion criteria were as follows: 1) Protocol papers and conference abstracts 2) Study with other Albucasis surgical Procedures and 3) Studies not published in English.

Related research works

This section summarizes previously published research studies to facilitate comparison with the present work and provides an overview of the current literature on perineal cystolithotomy from multiple perspectives Elcioglu et al.¹⁶ conducted a systematic review on urinary bladder stone extraction and surgical instruments described in the surgical textbooks of Abu’l-Qasim Khalaf Ibn Abbas Al-Zahrawi (Albucasis) (930–1013) and Serefeddin Sabuncuoglu (1385–1470). Their study examined the surgical techniques, tools, and surgical procedures related to bladder stone management in the urologic sections of both works. Their review supported the conclusion that Perineal cystolithotomy well explained in the Al-Tasrif. More recently, Rabie et al.¹⁷ conducted a study on the “Extraction of urinary bladder stone as described by AbuI-Qasim Khalaf Ibn Abbas Al-Zahrawi (Albucasis) (325-404 H, 930-1013 AD)” A translation of the original text, accompanied by scholarly commentary, provides a detailed account of the cystolithotomy technique practiced by the renowned Muslim surgeon Al-Zahrawi (Albucasis).

Results

Alzahrawi’s description of the extraction of urinary bladder stones in Al-Tasrif

Chapter-60 on the Extraction of the Stone. ‘‘At the beginning of bladder stone treatment, An enema should be administered to clean the patient’s bowels “This is necessary, as fecal matter may obstruct the procedure and interfere with identifying the stone.” Subsequently , the patient was lifted by the legs and shaken downward to facilitate displacement of the stone toward the bladder neck or, he could jump from a height many times. For the purpose of tilt the bladder downward, “sit him erect facing you with his hands placed beneath his thighs”. Then examine anal canal for the search of the stone by palpating him externally. If the stone is palpated within the rectal lumen, it should be crushed immediately. However, if the stone cannot be felt on digital examination, reinsert the lubricated finger into the anal canal and continue to search for it. Once the stone is detected and comes beneath the examining finger, gradually guide it, little by little, toward the bladder neck. Press firmly with your finger, advancing the stone outward toward the point at which the incision is to be made. Request an assistant to gently compress the bladder with their hand. Another assistant should retract the testicles with their right hand and, with the other hand, draw the skin below them downward to maintain exposure of the operative site. Then, take the Al-Nashl scalpel and make an incision between the anus and the testicles, positioned slightly to the left of the midline toward the left buttock. The incision should be made directly over the stone while your finger in the anus presses it outward. The incision should be made obliquely and only wide enough to permit the passage of the stone. It must not be enlarged unnecessarily, as digital pressure from within the anus will assist in its easy extrusion. Some important points to be remember in the, management of stone. Symptoms include passing thin, watery urine containing sand-like particles, and the patient often rubs or plays with the penis due to discomfort.¹⁶

Advice from Alzahrawi’s if there is still a problem with the extraction

If you still cannot take out the stone, expand the incision slightly. If bleeding occurs, it should be controlled using sulfuric acid, as recommended in historical surgical practices. When multiple stones are present, first push the largest stone toward the bladder neck and incise over it, then extract the smaller ones. Avoid making an excessively large incision, as this may lead to stool incontinence. Instead, the stone should be carefully manipulated out, or the Al-Kalbatain instrument may be used to break it into pieces for removal.¹⁶

Explanation of bladder stone removal procedure

Bladder stone removal is one of the earliest known surgical procedures. Traditionally performed through a perineal incision. Ancient Greek and Roman medicine did not practice preoperative bowel preparation with enemas. Mohamed Ibn Zakariya Razi (Rhazes) (841–926 AD) was the first to describe the use of enemas for bowel preparation before bladder stone surgery. In his book Alhawi Alkabeer (The Continens),“ He noted that stools present in the rectum can hinder or even prevent the palpation and localization of bladder stones. Therefore, giving an enema prior to the examination is essential. Once the bowels are emptied, both abdominal palpation and identification of the stone become considerably easier.” The Iranian physician Al-Razi designed a strong metallic pincer called the Almajarrah to firmly grasp.  A piece of the bladder stone that was intended to come out through a little cystotomy in the perineum. This instrument was then used to break the stone into smaller pieces until it was small enough to be removed.²⁰ The choice of finger for the per-rectal examination depends on the size of the anal orifice, which varies with the patient’s age. The assistant applies downward pressure over the suprapubic region. Maintaining this pressure on the bladder prevents the stone from slipping away from the surgeon’s left index finger, which is positioned in the rectum to secure the stone near the bladder neck.²² Assigning this task to an assistant allows the surgeon’s right hand to remain free for performing the subsequent steps of the operation. While the surgeon’s left hand maintains per rectal fixation of the stone, an assistant is required to retract the testicles and tension the skin at the incision site. Most likely, Al-Razi (Rhazes) used Meges’s scalpel, which he referred to as Al-Imadein, providing a more precise description of its shape. The incision made by Al-Imadein was not perfectly circular, a design intended to facilitate deeper penetration. It is likely that Al-razi (Rhazes) employed a scalpel similar to that described by Meges, which is referred to as “Al-Imadein”. He described a detailed description of its shape, and stated that “The incision is then made by “Al-Imadein, which is not completely circular, to facilitate deeper penetration. Al-Zahrawi pioneered the design of a lithotomy scalpel distinguished by two sharp cutting edges, an innovative instrument previously undocumented in surgical literature and meticulously rendered its illustration. This instrument, known as the Novacula, was later adopted by the Italian surgeon Marianus Sanctus in the sixteenth century and by the English surgeon Shelsden in the eighteenth century.¹⁷ Moreover, Al-Zahrawi is regarded as the earliest surgeon to make use of forceps for the extraction of stones from the bladder. Prior to his innovation, stones were removed using an instrument resembling a small spoon, which encircled the calculus and scooped it out. Al-Razi (Rhazes) used this spoon-like instrument, which he called Almajarrah meaning “the dragger” or “the scoop”. However, he also described that, when extracting a stone out, it may be necessary to use the Al-Kalbatain, an instrument similar to arrow extractor forceps. Nevertheless, Al-Zahrawi introduced a new instrument specifically designed for this purpose, offering a superior grip on the stone.¹⁸, ²¹

Perineal cystolithotomy by Celsus

 Perineal lithotomy was comprehensively described by Celsus in the first century AD and was subsequently known for many years as the methodus Celsiana. This procedure was most effective in children under 14 years of age, as prostatic enlargement in adults rendered the operation significantly more challenging. During the procedure, children were securely held in the lap of a strong assistant, whereas adult patients were restrained in the lithotomy position by three or four attendants. The surgeon inserted one or two fingers into the rectum to press the stone against the perineum. An incision was then made anterior to the anus, extending toward the region of the bladder trigone. The stone was removed either manually or with the aid of a hook. This simple technique was called the apparatus minor. Around 1520, a more radical operation was introduced in Italy and later popularized by Marianus. Owing to the numerous instruments required, this new approach became known as the apparatus major. ²³

Surgical instruments used in perineal cystolithotomy by Alzahrawi

Al-Zahrawi played a Significant role in the evolution of urology, particularly in the surgical management of bladder stones, and is widely recognized by Spink and Lewis as the founder of lithotripsy and Kirkup ^{31, 32} He introduced innovative instruments such as forceps, the drill (mithqab), scalpel, and the metal probe (mirwed) that revolutionized bladder stone surgery by reducing procedural risks and enhancing patient safety and outcomes. Al-Zahrawi’s forceps were specifically designed to crush large bladder stones, functioning as a primitive lithotrite that facilitated their gradual removal. In the 18th century, Andreas A. Cruce introduced a significant modification by replacing manual handle compression with a screw mechanism, thereby enhancing both precision and operative control. In the 19th century, Heurtloup further advanced Al-Zahrawi’s lithotrite by replacing the jointed, saw-toothed blades with separated parallel blades, thereby enhancing both the efficiency and safety of stone fragmentation. ^{33, 34}  The drill, crafted from Damascene steel with a sharp triangular tip and a wooden handle, was used to perforate residual small stones that migrated toward the urethra and obstructed urinary flow. Al-Zahrawi manually rotated the drill to pierce the stone, thereby facilitating its extraction and subsequent bladder irrigation ³⁵ Rigal de Gaillac, Fournier de Lempdes, and Franz von Gruithuisen employed drills whose designs closely resembled Al-Zahrawi’s original instrument. By the 19th century, Al-Zahrawi’s drill was replaced by a rotating-wheel mechanism developed by Leroy d’Ettiole and later improved by Jean Civiale. ^{35, 36, 37 .} Al-Zahrawi introduced the use of a scalpel in lithotripsy to make a perineal incision between the anus and the testicles. This instrument differed from the scalpel described by Meges of Sidon in the first century, which was characterized by two sharp cutting edges. In contrast, Al-Zahrawi’s design featured a broad, blunt upper edge that enabled the surgeon to apply controlled pressure, while the semicircular lower edge was sharpened for precise cutting. Meges of Sidon, one of the most prominent Methodic surgeons of the late first century B.C.E. and the most significant Roman surgeon prior to Galen, is credited with designing a double-edged blade for removing stones from the bladder neck. His lithotomy blade remained in use well into the middle Ages. ³⁷

Discussion

Among the earliest recorded surgical interventions was the removal of bladder stones. The procedure used a perineal incision extending to the bladder neck, followed by the extraction of the stone. This operative description invites comparison with techniques documented in ancient Indian civilization. Al-Zahrawi’s modifications and innovations disseminated throughout Europe during the Middle Ages and remained widely practiced until the early eighteenth century, when the suprapubic approach gradually replaced the perineal method as the preferred technique for bladder stone removal.^{19, 20.} There are three possible approaches to the bladder calculi removal one of three methods a perineal incision to the bladder base, a suprapubic opening above the pubis or crushing the stone using instruments introduced through the urethra.^{23, 24, 25}  French barber-surgeon Pierre Franco (c. 1500–1565) made numerous significant contributions to early surgical practice. He was among the first to clearly describe and successfully perform suprapubic lithotomy.²⁶ By the beginning of the 18th century, James Douglas (1675–1742) was a Scottish anatomist best known for describing the Pelvic Peritoneal pouch, now called the Pouch of Douglas (recto-uterine pouch) Douglas specifically examined the peritoneal reflections and fascial planes, aiming to identify safe surgical approaches to the bladder, crucial for procedures like lithotomy.^{27, 28.}Jean Civiale (1792–1876) first demonstrated a lithotritic instrument on January 13, 1824, which enabled the crushing and subsequent removal of bladder stones via the urethra.²⁹

Conclusion

The importance of Albucasis (Al-Zahrawi) in the beginnings and early stages of perineal cystolithotomy is highlighted by this thorough historical review. As one of the foremost surgical innovators of the Islamic Golden Age, Albucasis provided the first detailed descriptions of bladder stone removal via the perineal route, laying the foundation for centuries of urological practice. His emphasis on precision, specialized instruments, and patient selection reflects a remarkably advanced understanding of surgical principles for his time. Despite the high risks associated with the procedure in the absence of anesthesia and asepsis, Albucasis’s contributions demonstrate a rational, methodical approach grounded in observation and experience, marking a significant departure from earlier, more empirical traditions. His work not only influenced medieval surgical texts in Europe but also exemplified the integration of scientific knowledge with clinical skill. Understanding the historical roots of cystolithotomy through Albucasis’s legacy offers valuable insight into the evolution of urological surgery and the enduring impact of early Islamic medical scholarship.

Acknowledgement

The authors extend their sincere gratitude to the Director of the National Institute of Unani Medicine for valuable guidance, conceptual support, and continuous encouragement throughout the preparation of this manuscript. They also wish to thank the Director General of the Central Council for Research in Unani Medicine for providing essential support and facilitation in the execution of this research work.

Funding Source

This study was conducted without financial support from any public, commercial, or not-for-profit funding agency.

Conflict of interest: 

The authors disclose no competing interests and no financial support that may have impacted the conduct or outcomes of this research.

Author Contribution:

Aeliya Rukhsar: Conducted the literature review, gathered the majority of references, and contributed to the compilation and drafting of the manuscript.

Saiyad Shah Alam: Conceptualization and Supervision, Critically reviewed the whole manuscript. 

Jamal Akhtar: Edited the manuscript 

Ghazala Javed:  Edited the manuscript,

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