Serenoa Repens (Saw Palmetto) for Lower Urinary Tract Symptoms (LUTS): The Evidence for Efficacy and Safety of Lipidosterolic Extracts. Part III
Abstract
:1. LSESr and the Placebo Effect: Is There a Resolution?
How Can We Address the Negative Clinical Trials of LSESr vs. Placebo in Male LUTS?
2. Therapeutic Comparator Studies of LSESr vs. LUTS
2.1. HESr and EESr Are Not Inferior to Tamsulosin or to Finasteride
2.2. LSESr Efficacy Is Greater in Severe vs. Moderate LUTS
3. Peer-Reviewed Evaluable Studies of LSESr vs. LUTS
3.1. Fifty-five out of Fifty-Eight Evaluable Studies Indicate Efficacy
3.2. Previous Key Assessments of the Literature (Novara and Vela-Navarrete)
4. In the Final Analysis, the Effect of LSESr vs. LUTS Is Not a Placebo Effect
5. Extract Quality May Affect LSESr Efficacy
6. The Extraction Process Does Not Correlate with the Efficacy of LSESr Products vs. LUTS
7. Milieu Factors Are Important When Assessing LSESr vs. LUTS
8. Clinical Perspective
9. Addendum
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Author (Lead) | Year | Extraction Process | Pt. # | Study (mos) | IPSS | BPHII | Qmax | Fatty Acids % | |||
---|---|---|---|---|---|---|---|---|---|---|---|
Δ | % | Δ | % | Δ | % | ||||||
Bent | 2006 | CO2 | 102 | 12 | −0.7 | 4 | −0.3 | 10 | +0.4 | 4 | 92 TFA |
Placebo | 104 | −0.7 | 5 | −0.1 | 3 | −0.0 | 0 | ||||
Barry | 2011 | Ethanol | 151 | 18 | −2.2 | 15 | −0.8 | 24 | −0.2 | −1 | 54 FFA |
Placebo | 155 | −3.0 | 20 | −1.0 | 33 | −0.8 | −5 |
Author (Lead) | Year | Extraction Process | Pt. # | Study (mos) | IPSS * | QoL | Qmax | Fatty Acids % | |||
---|---|---|---|---|---|---|---|---|---|---|---|
Δ | % | Δ | % | Δ | % | ||||||
Barry | 2011 | Ethanol | 151 | 18 | −2.2 | 15 | −0.4 | 11 | −0.2 | −1 | 54 FFA |
Placebo | 155 | −3.0 | 20 | −0.5 | 15 | −0.8 | −5 | ||||
Derakhshani | 1997 | Ethanol | 1461 | 3 | −7.4 | 40 | −1.6 | 46 | +3.7 | 31 | 54 FFA |
No Placebo |
Lead Author Year, Ref. [#] | Study Duration (mos) | Study Arm | Patients (#) a | IPSS * | QoL * | Qmax * | |||
---|---|---|---|---|---|---|---|---|---|
Δ | % | Δ | % | mL/s | % | ||||
Debruyne 2002 [10] | 12 | HESr | 350 | −4.4 | 28 | NR | NR | +1.9 | 17 |
Tam | 354 | −4.4 | 29 | NR | NR | +1.8 | 16 | ||
Latil 2015 [11] | 3 | HESr | 83 | −4.5 | 25 | −0.9 | 23 | +1.7 | 15 |
Tam | 86 | −6.5 | 39 | −1.3 | 34 | +2.1 | 20 | ||
Alcaraz 2020 [12] ‡ | 6 | HESr | 222 | −5.6 | 30 | −1.3 | 34 | +3.3 | 25 |
Tam | 222 | −5.9 | 32 | −1.4 | 36 | +2.8 | 23 | ||
Combo | 159 | −7.3 | 37 | −1.8 | 46 | +2.1 | 16 | ||
Carraro 1996 [13] | 6.5 | HESr | 467 | −5.8 | 37 | −1.4 | 38 | +2.7 | 25 |
Fin | 484 | −6.1 | 39 | −1.5 | 41 | +3.2 | 30 | ||
Hizli 2007 [14] | 6 | EESr | 20 | −6.1 | 34 | −2.6 | 62 | +3.2 | 34 |
Tam | 20 | −4.6 | 28 | −2.1 | 60 | +3.7 | 35 | ||
Combo | 20 | −4.9 | 31 | −2.2 | 63 | +4.2 | 42 | ||
Argirovic 2013 [15] | 6 | EESr | 97 | −6.1 | 34 | −2.6 | 38 | +3.2 | 34 |
Tam | 87 | −4.6 | 28 | −2.1 | 40 | +3.7 | 35 | ||
Combo | 81 | −4.9 | 31 | −2.2 | 37 | +4.2 | 45 |
IPSS Value | PERMAL 2002 | PERMAL 2004 | ||
---|---|---|---|---|
Δ (%) IPSS | Δ (%) IPSS | |||
Permixon | Tamsulosin | Permixon | Tamsulosin | |
>10 | −4.4 (28%) | −4.4 (29%) | ||
>19 a | −7.8 (35%) | −5.8 (25%) | ||
=20–21 (all) | −6.9 | −5.5 | ||
=20–21 irritative | −2.5 | −2.0 | ||
=20–21 obstructive | −4.4 | −3.5 | ||
>21 (all) | −9.3 | −6.0 | ||
>21 irritative | −3.5 | −1.9 | ||
>21 obstructive | −5.8 | −4.1 |
Author (Lead) | Year | Extraction (Method) | Pt. # | Duration (mos) | IPSS | QoL | Qmax | Fatty Acids% | |||
---|---|---|---|---|---|---|---|---|---|---|---|
Δ | % | Δ | % | Δ | % | ||||||
Carraro α | 1996 | Hexane | 467 | 6 | −5.8 | 37 | −1.4 | 38 | +2.7 | 25 | 81 |
Stepanov β | 1999 | Hexane | 92 | 3 | −6.4 | 33 | −1.0 | 26 | +1.6 | 18 | 81 |
Al-Shukri | 2000 | Hexane | 57 | 2 | −2.2 | 27 | −0.6 | 18 | +0.7 | 6 | 81 |
Debruyne γ | 2002 | Hexane | 350 | 12 | −4.4 | 28 | +1.9 | 17 | 81 | ||
Giannakopoulos δ | 2002 | Hexane | 100 | 6 | −8.0 | 40 | −0.6 | 17 | +3.7 | 40 | 81 |
Pytel ε | 2002 | Hexane | 116 | 24 | −5.3 | 42 | −1.3 | 40 | +1.2 | 10 | 81 |
Debruyne θ | 2004 | Hexane | 124 | 12 | −7.8 | 35 | −1.2 | 29 | +1.2 | 11 | 81 |
El-Demiry ι | 2004 | Hexane | 190 | 6 | −11.4 | 51 | +4.4 | 45 | 81 | ||
Djavan Ω | 2005 | Hexane | 88 | 24 | −1.0 | 17 | −0.4 | 19 | +1.8 | 15 | 81 |
Giulianelli | 2012 | Hexane | 591 | 6 | -5.6 | 32 | +3.0 | 28 | 81 | ||
Latil κ | 2015 | Hexane | 83 | 3 | −4.5 | 25 | −0.9 | 23 | +1.7 | 15 | 81 |
Robert | 2015 | Hexane | 102 | 2 | −4.5 | 25 | 81 | ||||
Alcaraz | 2020 | Hexane | 222 | 6 | −5.6 | 30 | −1.3 | 34 | +3.3 | 25 | 81 |
Hexane Averages | n= 12 | 207 | 9 | −5.5 | 33 | −0.9 | 26 | +2.2 | 21 | 81 | |
Gerber λ | 1998 | Ethanol | 46 | 6 | −7.6 | 37 | −0.7 | −5 | 40 | ||
Hizli μ | 2007 | Ethanol | 20 | 6 | −6.1 | 34 | −2.6 | 62 | +3.2 | 34 | 81 |
Barry Ϸ | 2011 | Ethanol | 151 | 18 | −2.2 | 15 | 54 | ||||
Gerber ν | 2001 | Ethanol | 39 | 6 | −4.4 | 26 | −0.7 | 21 | +1.0 | 10 | 41 |
Sinescu π | 2011 | Ethanol | 120 | 24 | −5.5 | 40 | −1.8 | 50 | +5.6 | 54 | 59 |
Argirovic ρ | 2013 | Ethanol | 97 | 6 | −6.1 | 34 | −2.6 | 38 | +3.2 | 34 | 59 |
Cai | 2013 | Ethanol | 46 | 3 | −3.1 | 18 | +0.5 | 4 | -- | ||
Suter | 2013 | Ethanol | 69 | 2 | −7.5 | 52 | 95 | ||||
Saidi | 2019 | Ethanol | 40 | 12 | −2.1 | 18 | +0.8 | 6 | 59 | ||
Vinarov | 2019 | Ethanol | 30 | 180 | −6.0 | 50 | −3.0 | 60 | +5.0 | 45 | 59 |
Ye | 2019 | Ethanol | 159 | 6 | −4.4 | 29 | −1.2 | 26 | +4.1 | 36 | 68 |
ETOH Averages | n= 11 | 74 | 25 | −5.0 | 32 | −1.8 | 43 | +2.5 | 27 | 62 | |
Romics | 1993 | CO2 | 31 | 12 | +4.3 | 39 | 55 | ||||
Bach φ | 1996 | CO2 | 315 | 36 | 73 | +6.1 | 46 | 55 | |||
Kondas χ | 1996 | CO2 | 38 | 6 | +4.1 | 39 | 55 | ||||
Braeckman | 1994 | CO2 | 305 | 3 | −6.6 | 35 | −1.5 | 42 | +2.1 | 26 | 74 |
Braeckman ω | 1997 | CO2 | 67 | 12 | −10.2 | 60 | −1.5 | 42 | +2.6 | 24 | 74 |
Braeckman ψ | 1997 | CO2 | 125 | 3 | 64 | 30 | 74 | ||||
Willetts | 2003 | CO2 | 46 | 3 | −1.1 | 8 | −0.5 | 13.0 | +2.4 | -- | -- |
Bent | 2006 | CO2 | 102 | 12 | −0.7 | 4 | +0.4 | 4 | 92 | ||
CO2 Averages | n= 8 | 129 | 10.9 | −4.7 | 41 | −1.2 | 32 | +3.2 | 30 | 68 | |
Averages All | 194 | 15.0 | −5.1 | 35 | −1.3 | 34 | +2.6 | 26 | 70 | ||
IPSS, QoL & Qmax values are rounded off to one decimal point. Percentages are rounded off to the nearest whole number. The Hutchison 2007 study was not shown because it was a group analysis, but it is a valuable study. Since Latil 2015 and Robert 2015 contain identical content that was reported in two different journals, Robert 2015 was arbitrarily excluded from the table. α Carraro study of Permixon vs. finasteride. HESr showed equivalent efficacy to 5ARI with fewer side effects. β Stepanov study comparing Permixon at 160 mg bid vs. 160 mg ×2 once a day. Average results used. γ Debruyne 2002 study of Permixon vs. tamsulosin study with 4-week run-in phase. No significant differences in the effect of Permixon vs. tamsulosin 0.4 mg/day. δ Giannakopoulos study compared 160 mg bid vs. 160 tid. The results shown are the average of both findings. Qmax with 480 mg/day +4.54 vs. +2.8 for 320 mg/day. ε Pytel reported that 46–69% of patients reported improvement in obstructive and irritative symptoms from month-6 to the study’s end at 2 years. θ Debruyne 2004 subset analysis of high >19 IPSS patients with randomization between Permixon vs. tamsulosin. ι El-Demiry is an abstract but with solid data. Ω Djavan study on prevention of progression of LUTS from mild to greater than mild; Permixon vs. WW. Κ Latil study comparing Permixon vs. tamsulosin and correlations with inflammation. λ Gerber 1998 noted improvement at 2 months. At 6 months, 46% of patients with ≥50% (21/46) improvement. μ Hizli 2007 study comparing Prostagood® (ethanol extraction) vs. tamsulosin vs. Prostagood + tamsulosin. All groups with no significant differences in efficacy; Prostagood + tamsulosin did not increase efficacy. Ϸ Barry study is a negative study and the placebo group had Δ in IPSS of −2.99 or 20% improvement. ν Gerber 2001 study a with one-month placebo run-in for all patients. π Sinescu used Prostamol Uno. ρ Argirovic study compared Prostamol Uno 320 mg/day vs. tamsulosin vs. tamsulosin + Prostamol uno; percentage improvements were 33.9% vs. 28.4% vs. 31.4%, respectively for IPSS. Results were 38% vs. 40% vs. 37% for QoL; and for Qmax they were 34% vs. 35% vs. 44.5%, respectively. φ Bach 1996 3-year study quantitated nocturia, frequency, and incomplete emptying. Nocturia improved 73%, and no nocturia or nocturia ×1 increased from 33% to 85%. Improvements in frequency and incomplete emptying of 54% and 76%, respectively. χ Kondas used Strogen® Forte, aka Sabal IDS 89, (Strathmann GmbH & Co. KG, Hamburg, Germany). The authors stated they measured IPSS but did not report results. ω Braeckman 1997 study #1 used Prostaserene® as LSESr. QoL is not from IPSS but only a rating scale. Only 67 patients completed the study, with 34 patients receiving LSESr at 160 mg bid and 33 patients receiving 320 mg/day. ψ Braeckman 1997 study with calculations done by SBS. For placebo, IPSS improved 25% and Qmax improved 10%. |
Lead Author | Ref. [#] | Year | Extraction Method | Serenoa Patients (#) a | Study Duration(mos) | IPSS | QoL | Qmax | |||
---|---|---|---|---|---|---|---|---|---|---|---|
Δ | % b | Δ | % | Δ | % | ||||||
Cirillo-Marucco | [24] | 1983 | Hexane | 47 | 4 | 56 ε | +4.6 | 50 ε | |||
Cukier ψ | [25] | 1985 | Hexane | 73 | 2 | 33 λ | |||||
Tosto | [26] | 1985 | Hexane | 20 | 3 | −5.0 | 28 Ω | ||||
Pannunzio | [27] | 1986 | Hexane | 30 | 2 | +5.1 | 74 | ||||
Pescatore | [28] | 1986 | Hexane | 30 | 3 | +2.5 | 27 | ||||
Authie | [29] | 1987 | Hexane | 500 | 3 | 78 π | |||||
Ollé Carreras | [30] | 1987 | Hexane | 40 | 2 | 68 φ | |||||
Orfei | [31] | 1988 | Hexane | 30 | 3 | 50 χ | −2.2 | +0.0 | 0.2 | ||
Dathe | [32] | 1991 | Hexane | 49 | 6 | +5.9 | 49 | ||||
Aliaev | [33] | 2002 | Hexane | 26 | 60 | −8.8 | 76 | −1.3 | 53 | +4.1 | 35 |
Foroutan | [34] | 1997 | Hexane | 592 | 3 | −6.5 | 38 | −1.5 | 45 | +5.9 | 66 |
Medeiros α | [35] | 2000 | Hexane | 130 | 3 | −6.5 | 37 | −1.4 | 39 | +2.0 | 22 |
Totals Hexane (12) | Averages | 131 | 7.8 | −6.7 | 52 | −1.6 | 46 | +3.8 | 40 | ||
Derakhshani | [4] | 1997 | Ethanol | 1047 | 3 | −7.4 | 40 | −1.6 | 46 | +3.7 | 31 |
Eickenberg * | [20] | 1997 | Ethanol | 6967 | 6 | −8.0 | 44 | −1.8 | 38 | +3.0 | 23 |
Redecker ** | [36] | 1998 | Ethanol | 50 | 3 | 48 ν | +3.4 | 24 | |||
Ziegler ** β | [37] | 1998 | Ethanol | 109 | 3 | 36 | +3.7 | 29 | |||
Breza | [18] | 2005 | Ethanol | 596 | 12 | −5.9 | 36 | −1.7 | 54 | +2.3 | 19 |
Aliaev | [38] | 2007 | Ethanol | 50 | 6 | −3.0 | 26 | −1.8 | 43 | +1.7 | 14 |
Razumov | [39] | 2007 | Ethanol | 30 | 6 | −6.9 | 43 | −2.7 | 68 | +2.8 | 23 |
Aliaev γ | [40] | 2009 | Ethanol | 50 | 24 | −4.2 | 37 | −2.2 | 52 | +2.7 | 21 |
Vinarov | [41] | 2010 | Ethanol | 50 | 36 | −6.0 | 50 | −2.0 | 50 | +4.5 | 39 |
Aliaev | [42] | 2013 | Ethanol | 38 | 120 | −1.3 | 12 | −1.1 | 35 | +3.3 | 26 |
Totals Ethanol (10) | Averages | 899 | 22 | −5.3 | 37 | −1.9 | 47 | +3.1 | 25 | ||
Mattei ψ | [43] | 1990 | CO2 | 20 | 3 | 55 ω | |||||
Vahlensieck | [44] | 1993 | CO2 | 1334 | 4 | 39;55 Ϸ | |||||
Vahlensieck | [45] | 1993 | CO2 | 400 | 3 | 94 θ | +5.8 | 52 | |||
Fabricius δ | [46] | 1993 | CO2 | 153 | 6 | 39;58 δ | |||||
Bauer ψ | [47] | 1999 | CO2 | 101 | 6 | 37 ρ | 16 | ||||
Totals CO2 (5) | Averages | 402 | 4.4 | 34 | |||||||
Mean Across All Studies (n = 27) Hexane extraction (n = 12) Ethanol extraction (n = 10) Carbon dioxide extraction (n = 5) | 477 | 12 | −6.0 | 45% | −1.7 | 47% | +3.5 | 33% | |||
The clinical endpoints of IPSS, QoL and Qmax are rounded off to two significant digits. Percentages are rounded off to the nearest whole number. ≈, approximately; Δ, mean change; −, negative change; #, number; %, percent change; +, positive change; CO2, carbon dioxide; IPSS, International Prostate Symptom Score; mos, months; QoL, quality of life; Qmax, peak urinary flow (mL/s); Ref., citation reference. a The number of patients at study end, or as reported. ψ Placebo-controlled study. The study by Bauer was also double-blinded and randomized. α Medeiros study used a QoL scale 6 (worst) to 1 (best) rather than 6 (worst) and 0 (best). * Eickenberg used a 96% EESr. ** Redecker & Ziegler used a 90% EESr. β Ziegler did not use IPSS, so his reported symptoms were based on % improvement involving weak stream, hesitancy, incomplete emptying, frequency, and nocturia. γ Aliaev 2009 is a 2-year extension of the 6-month 2007 paper. δ Fabricius 1993 reported decreases in frequency and nocturia of 39%, and 58%, respectively. Nocturia ≤ 1 in 16% pre-LSESr vs. 79% at end of study (n = 153). ε Cirillo-Marucco study done before IPSS; raw data on nocturia; the study also included Qmax results. λ Cukier study done before IPSS; only raw data on nocturia. Ω Tosto study done before IPSS; authors used a unique point scoring to evaluate frequency, nocturia, incomplete emptying, weak stream. π Authie study before IPSS use; nocturia, frequency, and urgency improvements were 82%, 67%, and 85.3%, respectively (average improvement 78.1%); average complete resolution of these symptoms was 43.5%. φ Ollé Carreras did not use IPSS. The number shown is based on the change in frequency with complete resolution in 27 out of 40 patients. χ Orfei used scores from frequency, nocturia, urgency, weak stream, and straining at the beginning and end of the study ν Redecker data evaluated nocturia before and after LSESr. ω Mattei used scores from frequency, nocturia, and incomplete emptying. For these three endpoints, average improvement 55% vs. placebo average improvement of 1.4%. Ϸ Vahlensieck did not use IPSS. The data reflects the change in frequency and nocturia before and after LSESr. Frequency improved by 39% and nocturia by 55%. Θ Vahlensieck 2nd study reported an average decrease in frequency episodes of 94%. For nocturia, 59.5% of patients had ≤ 1 episode at end of the study vs. 9.7% at the start of the study. Ρ Bauer only indicated percentage improvement. Talso® Uno with 37% vs. 13% for placebo. |
Extraction Technology | Mean Patients # | Mean Study Duration (mos) | Included Studies | IPSS | QoL | Qmax | Typical FFA % | |||
---|---|---|---|---|---|---|---|---|---|---|
Δ | % | Δ | % | mL/s | % | |||||
Hexane n = 24 | 245 | 8.5 | All positive | −5.8 | 41 | −1.1 | 32 | +2.9 | 29 | Min ≈ 80 |
Ethanol n = 21 (1 negative) | 477 | 23 | All studies † | −5.1 | 34 | −1.8 | 45 | +2.8 | 25 | Min ≈ 70 |
Positive only | −5.3 | 36 | ||||||||
CO2 n = 13 (2 negative) | 228 | 8.4 | All studies | −4.6 | 43 | −1.2 | 32 | +3.5 | 31 | Min ≈ 65–70 |
Positive only | −8.4 | 53 | −1.5 | 42 | +4.2 | 34 |
Lead Author | Year | Study | Extraction | Product | Serenoa Patients δ | Placebo Patients δ | Study Duration (mos) |
---|---|---|---|---|---|---|---|
Boccafoschi | 1983 | D, P | Hexane | Permixon | 11 | 11 | 2 |
Emili | 1983 | D, P | Hexane | Permixon | 15 | 15 | 1 |
Mandressi | 1983 | D, P | Hexane | Permixon | 19 | 15 | 1 |
Champault | 1984 | D, P | Hexane | Permixon | 50 | 44 | 1 |
Tasca | 1985 | D, P | Hexane | Permixon | 14 | 13 | 2 |
Reece Smith | 1986 | D, P | Hexane | Permixon | 33 | 37 | 3 |
Löbelenz ‡ | 1992 | P | Ethanol | Sabal Extract | 30 | 30 | 1.5 |
Descotes | 1995 | D, P | Hexane | Permixon | 82 | 94 | 1 |
Cukier | 1985 | D, P | Hexane | Permixon | 71 | 76 | 2.5 |
Mattei | 1990 | D, P | CO2 | Talso® | 20 | 20 | 3 |
Braeckman | 1997 | D, R, P | CO2 | Prostaserene | 125 | 113 | 3 |
Bauer * | 1999 | D, R | CO2 | Talso® Uno | 101 | 6 | |
Gerber | 2001 | D, R | Ethanol | Solaray® | 39 | 40 | 6 |
Willetts | 2003 | R, C | CO2 | Proseren® | 46 | 47 | 3 |
Bent | 2006 | D, P | CO2 | Not stated | 102 | 104 | 12 |
Barry | 2011 | D, P | Ethanol | Prosta Urgenin Uno | 151 | 170 | 18 |
Ye | 2019 | D, P | Ethanol | Prostess® Uno | 159 | 169 | 6 |
Author (Lead) | Year | Ref. [#] | Serenoa Patients (#) δ | Study Duration (mos) | Key Results for Serenoa vs. Placebo or Comparator |
---|---|---|---|---|---|
Boccafoschi | 1983 | [52] | 11 | 2 | Qmax +4.2 (42%) vs. placebo +2.1 (20.6%) |
Emili | 1983 | [53] | 15 | 1 | Qmax +3.56 (34.5%) vs. placebo +0.20 (2.2%) |
Mandressi | 1983 | [56] | 19 | 1 | Serenoa vs. Pygeum vs. placebo; urgency 70% vs. 62% vs. 24%; frequency 30% vs. 22% vs. 10%; nocturia 42% vs. 38% vs. −4% |
Champault | 1984 | [63] | 50 | 1 | Qmax +2.7 (50.5%) vs. placebo +0.25 (5%); nocturia −1.53 (49%) vs. placebo −0.48 (15%) |
Tasca | 1985 | [54] | 14 | 2 | Qmax +3.3 (25.6%) vs. placebo −0.6 (−5%); nocturia 74.3% vs. 38.7%; urgency 60% vs. 20%; weak stream 50% vs. 16.6% |
Löbelenz | 1992 | [64] | 30 | 1.5 | Qmax +1.2 (9.8%) vs. placebo +0.6 (4.6%) |
Descotes | 1995 | [55] | 82 | 1 | Qmax +3.4 (28.9%) vs. placebo +1.1 (8.9%) |
Mean Across All Studies for Clinical Outcome | Qmax +3.0 (32%); ↓ nocturia 55%; ↓ urgency 65% |
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Strum, S.B. Serenoa Repens (Saw Palmetto) for Lower Urinary Tract Symptoms (LUTS): The Evidence for Efficacy and Safety of Lipidosterolic Extracts. Part III. Uro 2021, 1, 155-179. https://doi.org/10.3390/uro1030017
Strum SB. Serenoa Repens (Saw Palmetto) for Lower Urinary Tract Symptoms (LUTS): The Evidence for Efficacy and Safety of Lipidosterolic Extracts. Part III. Uro. 2021; 1(3):155-179. https://doi.org/10.3390/uro1030017
Chicago/Turabian StyleStrum, Stephen B. 2021. "Serenoa Repens (Saw Palmetto) for Lower Urinary Tract Symptoms (LUTS): The Evidence for Efficacy and Safety of Lipidosterolic Extracts. Part III" Uro 1, no. 3: 155-179. https://doi.org/10.3390/uro1030017