Porcelain gallbladder (PG) was historically associated with gallbladder cancer (GBC), (range 12-62%, largest series n = 26). Presently, cholecystectomy is still performed in many patients with PG. The objective of this study was to determine the incidence of GBC in patients with radiographic diagnosis of PG. We conducted a retrospective chart review of the Kaiser Permanente southern California electronic medical record database and identified patients with radiographic diagnosis of PG between 2008 and 2013. Extracted were patient demographics, imaging modality, symptoms, surgical and observational outcomes, and pathology results. Out of 192 PG patients, 102 underwent cholecystectomy, and 90 were observed. None of the patients in the surgery group had GBC on pathology review, and none of the observed patients developed GBC during follow-up (mean 3.5 years). In the surgery group, 82 per cent of the patients were asymptomatic with a perioperative complication rate of 10.7 per cent. Among symptomatic patients, the complication rate was 16.7 per cent. Rate of conversion to open surgery was 5 per cent. Complications led to eight endoscopic or percutaneous interventions and five additional operations. PG is not associated with increased risk of GBC but is associated with high risk of postoperative complications. Cholecystectomy should not be recommended in asymptomatic patients with PG.