It has been nearly fifty years since J.M. Smellie published a seminal work that changed the landscape of vesicoureteral reflux when he reported the outcomes of 116 children with chronic pyelonephritis and the benefits of chemoprophylaxis. Even then, he conceded "the effectiveness of any form of treatment will be known only after prolonged follow-up". Forty-six years later, the answers to many questions remain elusive. The surfeit of available information continues to provoke controversy - from the presentation of reflux to the management thereof. We endeavor to survey the rocky landscape of vesicoureteral reflux and provide a critical appraisal of the available evidence and challenges for the future.