Vesicular stomatitis virus (VSV) represents a significant advancement in therapeutic medicine, offering unique molecular and cellular characteristics that make it exceptionally suitable for medical applications. The bullet-shaped morphology, RNA genome organization, and cytoplasmic replication strategy provide fundamental advantages for both vaccine development and oncolytic applications. VSV’s interaction with host cells through the low-density lipoprotein receptor (LDL-R) and its sophisticated transcriptional regulation mechanisms enables precise control over therapeutic applications. The virus demonstrates remarkable versatility through its rapid replication cycle, robust immune response induction, and natural neurotropism. Recent technological innovations in VSV engineering have led to enhanced safety protocols and improved therapeutic modifications, particularly in cancer treatment. Attenuation strategies have successfully addressed safety concerns while maintaining the therapeutic efficacy of the virus. The molecular and cellular interactions of VSV, particularly its immune modulation capabilities and tumor-selective properties, have proven valuable in the development of targeted therapeutic strategies. This review explores these aspects, while highlighting the continuing evolution of VSV-based therapeutic approaches in precision medicine.