The structures and synthesis of polyzwitterions (“polybetaines”) are reviewed, emphasizing the literature of the past decade. Particular attention is given to the general challenges faced, and to successful strategies to obtain polymers with a true balance of permanent cationic and anionic groups, thus resulting in an overall zero charge. Also, the progress due to applying new methodologies from general polymer synthesis, such as controlled polymerization methods or the use of “click” chemical reactions is presented. Furthermore, the emerging topic of responsive (“smart”) polyzwitterions is addressed. The considerations and critical discussions are illustrated by typical examples.