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The same argument was used again with the current hospital administrative team when the new 4C unit with new software became available. This unit allowed a wider shot access with robotics, but many cases still required manual individual shot placement. With the building of one additional vault we now had 3 functional Gamma Knife units at Presbyterian University Hospital, now part of the growing University of Pittsburgh Medical Center (UPMC). The U unit was reloaded at year 10, but mostly used for simple cases such as trigeminal neuralgia and then eventually for radiobiological research [16–20]. At one point we had 1 unit at 100 cGy per min, one at 200 cGy, and one at 300 cGy. This facilitated looking at experimental models to see if the dose rate made any difference. It did not. We got hooked on robotics and more complex cases were triaged to the C units. Image-integrated software continually improved as Leksell GammaPlan released new updates (now over 14.2).

During this time, we began Gamma Knife radiosurgery training courses, first 2 weeks in length related to the long dose planning times, but eventually condensed to 1 intense week with didactic and practical training. We have trained more than 2,500 surgeons, oncologists, medical physicists, otologists, and nurses over 127 courses.